PAIN 


ITS  CAUSATION  AND  DIAGNOSTIC  SIG- 
NIFICANCE IN  INTERNAL 
DISEASES 

BY 

DR.  RUDOLPH  SCHMIDT 

ASSISTANT    IN    THE    CLINIC    OP    HOFRAT    VON    NEUSSER,   VIENNA 
TRANSLATED  AND  EDITED  BY 

KARL  M.  VOGEL,  M.D. 

INSTRUCTOR  IN  PATHOLOGY,  COLLEGE  OF  PHYSICIANS  AND  SURGEONS,   COLUMBIA 

UNIVERSITY;  CLINICAL  PATHOLOGIST  AND  ASSISTANT  ATTENDING 

PHYSICIAN,  ST.  LUKE'S  HOSPITAL 

AND 

HANS  ZINSSER,  A.M.,  M.D. 

INSTRUCTOR  IN  BACTERIOLOGY,  COLLEGE  OF  PHYSICIANS  AND  SURGEONS, 

COLUMBIA  UNIVERSITY;  ASSISTANT  PATHOLOGIST, 

ST.  LUKE'S  HOSPITAL 


PHILADELPHIA  &  LONDON 

J.  B.  LIPPINCOTT    COMPANY 


COPYRIGHT,  1908 
BY  J.  B.  LIPPINCOTT  COMPANY 


Manufactured,  by  J.  IS.  Lippincoft  Company 
The  Washington  Square  Press,  Philadelphia,  U.  S.  A. 


WB 
17* 
S3S3A 

HO* 

Translators'    Preface 

IN  undertaking  a  systematic  analysis  of  pain 
Dr.  Schmidt  lias  performed  a  useful  service.  The 
great  difficulties  attending  such  an  analysis  hardly 
need  to  be  emphasized  to  the  general  practitioner, 
who  is  so  often  called  upon  to  interpret  the  sub- 
jective complaint  in  terms  of  the  temperament  and 
individuality  of  the  patient.  In  fulfilling  his  task 
the  author  has  throughout  tempered  his  deductions 
from  actual  pathological  processes  with  a  careful 
critical  consideration  of  the  functional  elements 
which,  in  the  phenomena  of  pain,  so  frequently 
cloud  the  clinical  picture.  Wherever  possible,  how- 
ever, he  has  based  his  conclusions  upon  the  more 
exact  factors  of  anatomical  structure  and  patholog- 
ical change.  It  is  self-evident  that  in  the  considera- 
tion of  a  symptom  so  purely  subjective,  composed  of 
such  complex  psychological  and  pathological  ele- 
ments, the  final  interpretation  can  be  made  only  on 
the  basis  of  careful  clinical  observation.  The  subtle 
differences,  too,  which  may  exist  between  individual 
cases  of  similar  conditions  preclude  the  possibility 
of  formulating  absolute  rules.  The  author  can  but 
point  the  way  to  correct  analyses  and  logical  deduc- 
tion. Dr.  Schmidt,  in  the  performance  of  his  task, 
calls  upon  the  experience  of  many  years  with  a  huge 
clinical  material.  The  thoroughness  and  concise- 

5 


6  TRANSLATORS'   PREFACE 

ness  with  which  he  has  presented  his  subject  have 
seemed  to  the  translators  to  justify  the  preparation 
of  the  little  volume  for  the  use  of  American  mem- 
bers of  the  profession.  For  the  sake  of  complete- 
ness they  have  added  a  chapter  (X)  embodying 
a  brief  presentation  of  Head's  researches  on  re- 
ferred pains  and  a  series  of  diagrams  showing  some 
of  the  commoner  seats  of  pain  or  tenderness  in 
visceral  disease. 


Preface 

THE  manifestations  of  disease  that  are  apparent 
to  the  senses  of  the  examiner,  and  therefore  sus- 
ceptible of  objective  estimation,  are,  naturally,  espe- 
cially valuable  for  diagnostic  purposes.  Modern 
medical  research  accordingly  strives  to  facilitate 
the  solution  of  diagnostic  problems  by  investigations 
tending  in  this  direction,  such  as  the  study  of  serum 
pathology  and  radiology.  It  may  therefore  appear 
almost  like  a  step  backward  to  lay  as  much  stress 
on  a  phenomenon  that  is  so  purely  objective  in 
nature,  and  so  dependent  on  the  observations  of  the 
patient  himself,  as  will  be  done  in  the  following 
discussion  of  the  symptom  of  pain. 

In  this  undertaking  I  have  been  actuated  by  the 
following  considerations:  In  the  first  place,  the 
objective  evidences  of  disease  often  do  not  appear 
until  the  malady  has  reached  a  certain  degree  of 
development,  whereas  pain  is  not  rarely  present  at 
its  very  inception.  Furthermore,  under  the  condi- 
tions of  actual  practice  a  comprehensive  investiga- 
tion of  all  the  objective  symptoms  is  frequently  a 
matter  of  great  difficulty  owing  to  the  absence  of  the 
necessary  facilities,  and  therefore  a  careful  consider- 
ation of  the  patient's  own  sensations  is  absolutely 
essential.  Lastly,  it  is  frequently  this  very  symp- 
tom of  pain  that  impels  the  patient  to  seek  medical 

7 


8  PREFACE 

advice,  and  it  will  therefore  be  the  starting  point 
of  the  diagnostic  train  of  reasoning,  while  its  correct 
interpretation  is  the  first  requisite  to  the  institution 
of  a  suitable  form  of  treatment. 

On  the  other  hand,  both  during  the  ten  years  of 
my  service  in  the  clinic  of  my  honored  instructor, 
Hofrat  von  Neusser,  which  brought  me  in  constant 
contact  with  the  younger  members  of  the  staff,  and 
in  the  course  of  my  long-continued  activity  as  a  post- 
graduate instructor,  I  have  convinced  myself  that 
even  among  those  having  satisfactory  command  of 
the  methods  of  objective  examination  there  is  a  great 
deficiency  in  the  ability  to  make  use  of  the  infor- 
mation conveyed  by  the  manifestations  of  pain.  A 
realization  of  this  lack  was  another  reason  for  the 
preparation  of  the  present  volume. 

The  work  is  intended  especially  to  afford  a  gen- 
eral view  that  will  enable  rapid  orientation  in  the 
individual  case,  and  I  therefore  did  not  deem  it 
advisable  to  impair  its  continuity  by  the  introduction 
of  references  to  the  literature  or  of  polemical  dis- 
cussions. The  adoption  of  a  more  or  less  dogmatic 
method  of  presentation  seemed  justified  by  my  long- 
standing hospital  connection,  which  has  also  involved 
much  experience  in  teaching. 

In  discussing  the  manifestations  of  pain  it  has 
seemed  to  me  that  in  addition  to  the  organic  proc- 
esses to  which  they  were  due  and  the  topographical 
factors  underlying  their  projection  externally,  their 
relationship  to  function  was  especially  important 


PREFACE  9 

from  the  standpoint  of  facilitating  diagnosis.  The 
investigation  of  painful  conditions  from  this  point 
of  view  leads  to-  a  more*  intimate,  comprehension  of 
their  pathogenesis  and  therefore  to  greater  success 
in  treatment. 

May  the  book  fulfil  the  purpose  for  which  it  was 
written,  of  serving  as  a  guide  in  the  rapid  and 
correct  interpretation  and  successful  treatment  of 
the  pain  occurring  in  internal  diseases. 

SCHMIDT. 


Contents 


PAGE 

TRANSLATORS'  PREFACE 5 

AUTHOR'S  PREFACE 7 

CHAPTER  I. 

THE  SENSATION  OF  PAIN 15 

CHAPTER  II. 

THE  FUNCTIONAL  MODIFICATION  OF  PAIN 22 

The  Influence  of  Position 22 

The  Influence  of  Motion 26 

The  Influence  of  Pressure 29 

The  Influence  of  Food 33 

The  Influence  of  Drugs  and  Chemicals 38 

The  Influence  of  Organic  Function 41 

CHAPTER  III. 

TOPOGRAPHY  IN  ITS  RELATION  TO  PAIN 47 

The  Shoulder 48 

Retrosternal  Region 50 

Scapula  and  Interscapular  Region 51 

The  Epigastrium 53 

'  The  Abdomen  below  the  Umbilicus 56 

The  Lumbar  Region  (symmetrical) 57 

The  Lumbar  Region  (unilateral)  and  the  Flanks 58 

Atypical  Abdominal  Pains 59 

CHAPTER  IV. 

QUALITY  AND  TIME  OF  OCCURRENCE 65 

Colicky  Pains 65 

Nocturnal  Pains 67 

CHAPTER  V. 

THE  NERVOUS  SYSTEM 69 

Headache 69 

Due  to  Elevations  of  Intracranial  Pressure 71 

Caused  by  Chemical  Poisons 76 

Of  Reflex  Nature 78 

Neuralgias  Involving  the  General  Nervous  System 83 

The  Face 88 

The  Occipital  Region  and  Nape  of  the  Neck 90 

The  Arm 91 

Intercostal  Spaces,  including  Upper  Abdomen 92 

Flanks  and  Lower  Abdominal  Region 94 

Lower  Extremities 95 

Neuralgias,  Sympathetic  System  and  Vagus 97 

11 


12  CONTENTS 

CHAPTER  VI. 

PAGE 

ORGANS  OF  MOTION 103 

Joint  Pains  or  Arthralgias 103 

Muscular  Pains  or  Myalgias 108 

Bone  Pains  or  Ostalgias 115 

CHAPTER  VII. 

DIGESTIVE  SYSTEM 123 

Gastralgias 123 

Irritable  Weakness  of  Nervous  System 126 

Direct  Causes 126 

Pieflex  Causes 128 

Gastric  Ulcers 133 

The  Colic  of  Pyloric  Stenosis 153 

Gastric  Cancer 164 

Intestinal  Ulceration 174 

Diseases  of  the  Appendix 182 

Lead  Colic 192 

Malignant  New  Growths  of  the  Intestines 197 

Liver 206 

Gall-Bladder  Colic 209 

Pains  without  Colic 226 

Distention  and  Inflammation  Capsule 228 

Pancreas 240 

CHAPTER  VIII. 

URINARY  SYSTEM  AND  SPLEEN 249 

Kidney 249 

True  Kidney  Pains 249 

Muscular  Spasm,  Urogenital  Tract 262 

Urinary  Bladder 272 

Spleen 276 

CHAPTER  IX. 

RESPIRATORY  AND  CIRCULATORY  SYSTEMS 282 

The  Lungs 282 

Aorta 292 

Peripheral  Vessels 314 

CHAPTER  X. 

CUTANEOUS  TENDERNESS  IN  VISCERAL  DISEASE .   319 


List  of  Illustrations 

(At  End  of  the  Text) 

FIG. 

1.  Diagram,  anterior  view  of  the  human  body  showing  seg- 

mental  distribution  of  referred  pain  and  tenderness  in 
visceral  disease. 

2.  Diagram,  posterior  view  of  the  human  body  showing  seg- 

mental  distribution  of  referred   pain  and  tenderness  in 
visceral  disease. 

3.  Diagram,  lateral   view  of  the   human  body  showing  seg- 

mental   distribution  of  referred   pain  and  tenderness  in 
visceral  disease. 

4.  Diagram  of  head  and  neck,  showing  areas  of  referred  pain 

and  tenderness  related  to  visceral  disease  or  to  affections 
of  the  head  and  neck. 

5.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  nervous 

system,  etc. 

6.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  nervous 

system,  etc. 

7.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  abdom- 

inal organs,  etc. 

8.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  abdom- 

inal organs,  etc. 

9.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  abdom- 

inal organs,  etc. 

10.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  abdom- 

inal organs,  etc. 

11.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  abdom- 

inal organs,  etc. 

12.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  lungs 

and  pleura. 

13.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  lungs 

and  pleura. 

13 


14  LIST  OF  ILLUSTRATIONS 

FIG. 

14.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  lungs 

and  pleura. 

15.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  heart 

and  vessels. 

16.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  heart 

and  vessels. 

17.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  heart 

and  vessels. 

18.  Possible  areas  of  pain  or  tenderness  in  diseases  of  the  heart 

and  vessels. 


PAIN 


ITS  CAUSATION  AND  DIAGNOSTIC  SIGNIFICANCE 
IN  INTERNAL  DISEASES 


CHAPTER  I. 

THE   SENSATION   OF   PAIN. 

IN  order  to  combat  successfully  a  painful  sen- 
sation manifested  by  a  patient,  of  whatever  sort  it 
may  be,  it  is  necessary  first  to  obtain  a  clear  insight 
into  its  sources  of  origin.  The  more  deeply  we  are 
able  to  penetrate  into  these  the  more  successful  and 
to  the  point  will  be  our  therapeutic  measures.  A 
fundamental  principle  in  such  an  objective  study  is 
the  analysis  of  the 'painful  sensation  into  its  various 
elements,  its  relations  to  space  and  to  time,  its  char- 
acteristic qualitative  shading,  its  area  of  distribu- 
tion, associated  manifestations,  etc. 

TOPOGRAPHY. — The  analysis  of  a  pain  may  most 
suitably  be  commenced  by  determining  its  topo- 
graphical characteristics.  In  order  to  do  this  it 
should  be  made  a  rule  always  to  have  the  patient 
point  out  exactly  the  spot  or  the  region  in  which 
the  pain  is  felt,  and  specify  whether  it  is  superficial 
or  deep  seated.  Vague  statements,  such  as  pain  in 
the  stomach,  in  the  liver,  etc.,  are  of  little  value  and 
are  frequently  associated  with  totally  erroneous  con- 

15 


16  PAIN 

ceptions  regarding  the  situation  of  the  organ  in 
question,  so  that  they  serve  only  to  lead  astray. 

Where  the  pain  is  a  radiating  one  it  is  necessary 
to  differentiate  between  the  painful  focus  and  its 
peripheral  radiations.  In  such  cases  it  will  usually 
be  found  that  the  focus — often  from  the  diagnostic 
point  of  view  the  most  important  point — coincides 
with  the  area  in  which  the  pain  was  localized  at  the 
beginning  of  the  attack.  Of  no  less  significance  than 
the  location  of  the  painful  focus,  which  ordinarily 
is  at  least  in  proximity  to  the  etiological  point  of 
origin,  are  the  radiations  of  the  pain,  especially  in 
cases  in  which  there  is  no  ground  for  assuming  a 
neuropathic  tendency  in  the  patient.  If  the  opposite 
should  be  the  case,  however,  it  is  advisable  not  to 
attach  undue  importance  to  the  direction  of  radia- 
tion from  the  standpoint  of  differential  diagnosis. 
Under  these  conditions  one  must  be  prepared  to 
encounter  atypical  and  wholly  irregular,  bizarre  radi- 
ations. The  extent  of  the  area  involved  by  the 
radiation  of  the  pain  in  paroxysms  such  as  those  of 
biliary  and  ureteral  colic,  etc.,  frequently  appears 
to  be  directly  proportional  to  the  intensity  of  the 
neuropathic  tendency. 

In  considering  the  topography  it  is  also  essential 
to  take  into  account  multiplicity  or  symmetry  of  the 
pain,  if  present.  These  features  in  connection  with 
neuralgias,  arthralgias,  and  ostalgias  indicate  a 
broader  etiological  basis,  such  as  a  disorder  of  meta- 
bolism, and  speak  against  a  purely  local  causation. 

TIME. — A  natural  sequel  of  a  consideration  of 


ANALYSIS   OF  THE   SENSATION  17 

the  location  of  the  pain  is  that  of  the  time  of  its 
appearance.  Not  infrequently  the  onset  of  the  pain 
is  associated  with  some  definite  hour  of  the  day,  or 
exhibits  a  regular  dependence  on  certain  occur- 
rences, such  as  the  ingestion  of  food.  Or  it  may 
appear  at  some  stated  time  of  the  day  (for  example, 
nocturnal  pain),  and  it  is  then  our  task  to  determine 
the  factors  underlying  this  regularity  in  recurrence. 
Now  and  then  a  relation  to  larger  units  of  time,  such 
as  the  seasons,  or  distinct  phases  in  bodily  develop- 
ment, may  be  observed  and  open  up  perspectives 
in  the  direction  of  the  manner  of  causation.  The 
duration  of  the  painful  sensation  must  also  receive 
due  attention. 

INTENSITY. — The  purely  quantitative  variations, 
of  course,  depend  on  the  intensity  of  the  stimulus 
in  question,  but  not  less  so  on  the  sensitiveness  of 
the  registering  apparatus,  that  is,  the  patient's 
psychical  characteristics,  so  that  the  same  etiologi- 
cal  stimulus  may  appear  endurable  to  one,  but  may 
seriously  disturb  the  psychical  equilibrium  of  an- 
other. This  double  dependence  of  the  intensity  of 
the  painful  sensation  on  stimulus  and  irritability, 
and  the  impossibility  of  projecting  externally  the 
physicochemical  events  in  the  sensory  nerve  sub- 
stance that  take  place  when  pain  is  experienced,  ren- 
der illusory  attempts  at  the  quantitative  estimation 
of  the  sensation  for  diagnostic  purposes.  None  the 
less,  we  are  not  entirely  without  means  of  control, 
and  can  make  use  of  these  in  cases  in  which  doubt 

arises  regarding  the  credibility  of  the  patient. 
2 


18  PAIN 

SIMULATION. — Experience  shows  that  intense  and 
persistent  pain  in  the  course  of  time  nearly  always 
leads  to  more  or  less  serious  disturbances  in  the  con- 
dition of  the  body  as  a  whole,  so  that  disorders  of 
nutrition  are  produced  and  loss  of  weight  results. 
In  some  cases,  therefore,  systematic  observations 
of  the  patient's  weight  may  serve  as  a  means  of 
control  in  this  regard.  When  paroxysmal  pain  is 
complained  of,  the  determination  of  the  blood  pres- 
sure by  means  of  the  tonometer  [or,  preferably,  the 
sphygmomanometer]  is  to  be  recommended  in  sus- 
pected cases.  This  should  be  done  both  in  the  in- 
terval when  the  pain  has  subsided  and  at  the  height 
of  the  paroxysm.  From  analogy  with  the  labora- 
tory experiment  of  stimulating  the  sciatic  nerve 
an  elevation  of  the  vascular  tension  during  the 
paroxysm  is  to  be  expected,  and  in  fact  this  phe- 
nomenon may  often  actually  be  observed.  In  deal- 
ing with  patients  suspected  of  malingering  I  would 
suggest  that  if  pain  is  complained  of  on  pressure, 
the  size  of  the  pupils  be  observed  in  order  to  detect 
any  possible  increase  in  dilatation  that  may  follow 
the  painful  stimulus  (sympathetic  reflex).  If  this 
reflex  is  present  there  is  no  doubt  of  the  veracity 
of  the  patient  in  stating  that  he  is  experiencing  pain. 
It  is  advisable,  however,  to  obtain  some  insight  into 
the  patient's  susceptibility  to  reflexes  of  this  sort 
by  the  production  of  an  artificial  pain,  e.g.,  by  pinch- 
ing. Theoretically,  this  procedure  even  offers  the 
possibility  of  obtaining  an  insight  into  the  intensity 
of  the  original  pain  by  observing  the  degree  of 


ANALYSIS  OF  THE  SENSATION  19 

stimulation  necessary  to  evoke  the  same  reflex, 
assuming  that  equal  stimuli  produce  reflexes  of  equal 
intensities.  Reflex  phenomena  may  be  used  in  other 
ways  as  means  of  control  in  this  direction.  Such 
a  one  is  the  unilateral  increase  in  the  abdominal 
reflex  which  leads  to  the  symptom  of  muscular  rigid- 
ity (defense  musculaire]  occurring  in  abdominal 
conditions. 

QUALITY. — Patients  accustomed  to  close  self- 
observation  often  supply  information  in  regard  to 
the  quality  of  their  pains.  Not  infrequently  light 
may  be  thrown  on  the  pathogenesis  or  nature  of 
these  pains  through  the  description  which  the  patient 
gives  of  them  as  being  boring,  piercing,  colicky,  etc. 
Pain  resulting  from  muscular  spasm  is  often  experi- 
enced as  a  " cramp"  or  "griping."  In  cases  of 
overdistention  of  hollow  muscular  organs  this  phe- 
nomenon may  give  its  characteristic  shading  to  the 
pain,  and  the  pain  of  aneurysmal  erosion,  for  ex- 
ample, is  often  described  "as  if  something  was 
boring"  or  as  being  "pounding"  in  nature.  Ab- 
dominal pains  must  always  be  considered  with  re- 
gard to  the  presence  of  a  colicky  character.  The 
distinctive  feature  of  this  lies  in  its  wave-like  in- 
crease and  decrease,  frequently  accompanied  by  a 
sensation  of  griping,  "tying  up  in  a  knot,"  or  a 
feeling  of  overdistention. 

MODIFYING  FACTOKS. — The  exact  analysis  of  the 
pain  furthermore  demands  the  accurate  determina- 
tion of  all  of  the  factors  which  influence  the  inten- 
sity of  the  sensation,  either  in  the  positive  or  the 


20  PAIN 

negative  sense.  Such  modifying  factors  are  inti- 
mately connected  with  the  causative  condition  and 
are  therefore  of  the  greatest  importance  from  the 
diagnostic  point  of  view.  In  this  connection  stimuli 
of  general  nature  must  especially  be  considered. 

a.  Psychical. — Excitement,    diversion   of   atten- 
tion, suggestion  either  in  the  waking  condition  or 
under  hypnosis,  etc.    It  is  evident  that  painful  sen- 
sations that  have  what  may  be  termed  a  psychical 
origin  and  from  this  center  are  projected  to  some 
one  zone  of  the  periphery,  such  as  some  of  the  pains 
of  hysteria,  are  particularly  susceptible  to  psychical 
modification.    The  same  thing  is  true  of  pains  which 
are  peripheral  and  organic  in  origin  but  which  are 
brought  prominently  into  the  foreground  only  as  the 
result  of  abnormal  irritability  of  the  central  recep- 
tive organs.    In  such  cases  diverting  the  attention 
through  suitable  occupation  or  pastimes,  change  of 
surroundings,  etc.,  has  an  anodyne  action.    It  is 
never  permissible,  however,  from  such  an  observa- 
tion alone  to  consider  a  pain  as  being  of  purely 
psychical  nature.    At  the  most  it  is  justifiable  only 
to  assume  the  existence  of  a  contributing  component 
of  this  character. 

b.  Mechanical. — Position  of  the  body,  motion, 
solid  food,  percussion,  massage,  pressure,  concus- 
sion, etc. 

c.  Thermic. — Changes  of  weather,  draughts,  etc. 

d.  Electrical. 

e.  Chemical. — 1.  Dietetic. 

2.  Eemedial :  local  or  general. 


ANALYSIS  OP  THE  SENSATION  21 

Whenever  the  pain  appears  to  be  dependent  on 
certain  organic  conditions  or  organic  functions  it 
will  nearly  always  be  possible  on  careful  considera- 
tion to  discover  the  primary  causative  factor,  either 
in  the  group  of  the  mechanical  or  of  the  chemical 
cell  stimuli. 

ACCOMPANYING  MANIFESTATIONS. — Finally,  it  must 
not  be  forgotten  that  attention  should  be  directed 
to  any  possible  associated  manifestations,  whether 
these  are  of  a  purely  subjective  nature  or  are  also 
susceptible  of  objective  study.  Frequently,  of 
course,  these  are  only  remote  in  nature,  such  for 
example  as  the  vomiting  or  constipation  accompany- 
ing painful  abdominal  seizures  of  the  most  varied 
types,  but  sometimes  they  may  also  be  interpreted 
as  actual  local  symptoms  (peristalsis,  diarrhoea, 
dysuria,  icterus,  bleeding  from  the  genitals,  etc.). 

By  following  the  preceding  scheme  it  will  often 
be  possible  to  make  a  rapid  diagnosis  and  to  obtain 
a  point  of  departure  for  therapeutic  measures.  At 
least  the  diagnostic  possibilities  will  be  narrowed 
and  the  physical  examination  or  the  laboratory 
investigations  may  be  concentrated  in  a  smaller 
domain.  This  is  as  it  should  be,  for  not  only  accu- 
racy but  also  promptness  is  desirable  in  diagnosis. 


CHAPTER  II. 

THE  FUNCTIONAL  MODIFICATION  OF  PAIN. 

THE  INFLUENCE  OF  POSITION. 

IN  discussing  the  pain  associated  with  the 
various  organs  it  is  often  desirable  to  emphasize 
its  dependence  on  definite  positions  of  the  body, 
such  as  the  dorsal,  the  lateral,  etc.,  which  fre- 
quently appear  to  bear  a  distinct  relationship 
to  the  sensation.  Observations  of  this  sort  lead 
to  the  characterization  of  certain  "positions  of 
maximum  pain,"  which  term  may  be  applied  to 
those  positions  which  give  rise  to  a  pain  which 
previously  did  not  exist  or  which  increase  the  inten- 
sity of  a  pain  already  present.  In  so  far  as  the 
painful  position  depends  on  tenderness  to  pressure 
of  superficial  structures,  as  in  joint  affections,  etc., 
it  has  little  diagnostic  interest,  and  only  those  in- 
stances are  to  be  discussed  in  which  such  external 
causation  of  the  pain  is  not  involved.  In  gastric 
ulcer  the  existence  of  a  painful  position  has  been 
accorded  a  somewhat  unjustifiable  degree  of  im- 
portance from  the  standpoint  of  differential  diag- 
nosis, and  for  this  reason  the  interpretation  of  the 
symptom  is  not  always  clear  cut.  This  subject  will 
be  discussed  later  on  in  its  proper  place. 

As  a  matter  of  fact,  painful  positions  may  be 
discovered  in  connection  with  the  pain  complexes 
of  the  most  varied  organs,  and  this  therefore  points 
22 


FUNCTIONAL   MODIFICATION  23 

to  uniformity  in  the  mechanism  of  their  origin.  For 
example,  in  the  discussion  of  special  organs  refer- 
ence will  be  made  to  the  occurrence  of  painful  posi- 
tions in  diseases  of  the  gall-bladder,  of  the  appendix, 
in  abdominal  tumors,  aneurysms,  pericarditis,  etc. 
I  have  found  that  even  in  intracranial  processes,  such 
as  cerebellar  tumors,  there  may  be  painful  position 
in  regard  to  the  headache,  which  occurs  on  the  side 
opposite  to  that  of  the  hemisphere  in  which  the 
tumor  is  situated  and  may  depend  on  the  pressure 
of  the  growth  on  the  vena  magna  Galeni  or  the 
aqueduct  of  Silvius.  In  the  majority  of  cases  the 
most  general  cause  of  pain  is  to  be  sought  for  in 
a  change  of  position  of  the  diseased  organ,  such  as 
occurs  in  certain  positions  of  the  body.  All  the 
organs,  including  new  growths,  are  rather  loosely 
packed  in  the  body  cavities,  and  the  firmness  of  their 
fixation  is  very  variable,  as  is  shown  in  enteroptosis 
for  example. 

Painful  traction  on  diseased  organs  is  likely  to 
result  (especially  in  cases  of  inflammatory  processes 
in  the  immediate  neighborhood  of  the  structures 
involved,  as  in  perigastritis,  appendicitis,  periaor- 
titis,  etc.)  in  those  positions  of  the  body  in  which  the 
organ  is  deprived  of  its  firm  support.  This  is  ordi- 
narily the  case  in  the  position  on  the  side  opposed  to 
the  lesion,  and  the  resulting  pain  will  depend  on 
the  degree  of  sensibility  caused  by  the  inflammation 
and  on  the  intensity  of  the  traction,  i.e.,  on  the  weight 
and  mobility  of  the  displaced  mass.  Of  course  other 
factors  also  come  into  play,  such  as  pressure  on 


24  PAIN 

neighboring  nerve  trunks,  as  in  aneurysms,  tumors, 
etc.,  as  well  as  secondary  pressure  effects  on  mus- 
cular hollow  organs  like  the  stomach,  intestine, 
ureter,  etc.  A  special  mechanism  depending  on 
the  local  peculiarities  of  the  tissues  involved  under- 
lies the  position  of  maximum  pain  in  certain  diseases 
of  the  aorta  or  the  coronary  arteries.  It  is  well 
known  that  in  some  cases  of  these  the  horizontal 
position  may  give  rise  to  the  onset  of  painful  attacks 
of  angina  pectoris.  In  these  affections  the  causa- 
tive factor  is  probably  to  be  found  in  the  alterations 
in  the  circulation  produced  by  the  change  in  position, 
such  as  the  slower  but  more  powerful  cardiac  con- 
tractions with  a  possible  rise  in  arterial  pressure 
and  greater  lateral  tension  of  the  chronically  in- 
flamed aorta. 

What  light  is  thrown  on  the  problem  of  differ- 
ential diagnosis  by  the  discovery  that  there  is  in 
a  given  case  a  position  of  maximum  pain  ? 

1.  If  the  problem  presenting  itself  for  decision 
is  whether  the  pain  is  organic  or  functional  in 
nature,  the  existence  of  a  painful  position  is  in  favor 
of  an  organic  lesion.  Thus  in  cases  of  mediastinal 
new  growth,  including  carcinoma  of  the  oesophagus, 
aneurysm  of  the  thoracic  and  abdominal  aorta,  gas- 
tric ulcer,  etc.,  the  nature  of  the  attendant  pain  is 
not  rarely  misunderstood  and  is  considered  as  being 
a  functional  manifestation  of  a  neurosis.  Under 
these  conditions  the  demonstration  that  there  is  a 
distinct  position  of  increased  pain  may  be  of  deci- 
sive moment. 


FUNCTIONAL  MODIFICATION  25 

2.  The  presence  of  a  painful  position  always  in- 
dicates the  advisability  of  a  search  for  the  organ 
or  new  growth  causing  it,  and  the  location  of  the 
sensation  attending  the  painful  position  will  corre- 
spond to  the  situation  of  the  organ  or  new  growth 
in  question.  The  detection  of  deeply  situated 
tumors  involving,  for  example,  the  pancreas  or 
oesophagus,  is  often  a  matter  of  difficulty  and  in 
these  cases  the  presence  of  a  painful  position  may 
be  taken  as  being  corroborative  of  doubtful  palpa- 
tory  evidence.  The  occurrence  of  a  painful  position 
points  toward  a  localized  process,  especially  in  deal- 
ing with  the  abdomen,  even  when  the  pain  appears 
to  be  diffuse,  as  in  appendicitis,  intestinal  cancer, 
cholelithiasis,  nephrolithiasis,  etc.,  and  so  may  be 
of  service  in  differentiating  an  ordinary  intestinal 
colic  from  similar  painful  sensations  originating  in 
appendicular  disease  or  localized  carcinoma. 

The  lateral  posture  is  a  painful  position  par  ex- 
cellence, for  it  involves  the  most  favorable  condi- 
tions for  abnormal  displacement  and  traction.  The 
dorsal  position  (e.g.,  retroperitoneal  processes)  or 
the  sitting  posture  may  also  come  into  question, 
however.  In  the  latter  case  the  symptom  is  usually 
difficult  to  interpret.  Pain  in  the  small  of  the  back 
and  in  the  flanks  is  not  infrequently  caused  after 
long  sitting,  especially  if  the  body  is  inclined  for- 
ward, by  swollen  abdominal  organs  like  the  kidney, 
spleen,  liver,  etc.  These  pains  do  not,  however, 
appear  very  promptly,  but  only  after  long  contin- 


26  PAIN 

uance  of  the  position,  and  the  pain  may  sometimes 
also  be  explained  as  being  the  result  of  fatigue  of 
the  dorsal  musculature. 

THE  INFLUENCE  OF  MOTION. 

Under  this  heading  only  those  forms  of  pain  will 
be  discussed  that  are  modified  in  clearly  recognizable 
fashion  through  bodily  motion,  either  general  or 
local.  In  these  cases  the  pain  may  be  produced 
or  aggravated  as  if  by  carefully  planned  experi- 
mentation, and  the  differential  diagnosis  is  facili- 
tated by  tests  in  this  direction.  A  more  or  less 
superficial  connection  between  pain  and  bodily  mo- 
tion in  the  sense  that  rest  has  a  beneficial  effect 
is  very  widespread  and  may,  to  some  extent,  be 
explained  through  the  steadiness  of  the  circulatory 
conditions  (headache),  and  in  the  absence  of  me- 
chanical insults  (gastric  ulcer)  when  the  body  is  at 
rest.  On  the  other  hand,  there  is  a  group  of  painful 
sensations  that  appear  on  motion  as  the  inevitable 
result  of  the  general  pain  mechanism. 

1.  DISORDERS  OF  THE  ORGANS  OF  MOTION. — These 
are  maladies  usually  involving  the  extremities,  which 
are  accessible  to  careful  and  extensive  physical  ex- 
amination so  that  special  difficulties  are  not  likely 
to  be  encountered.  The  greatest  source  of  error  is 
to  be  found  in  the  fortunately  comparatively  rare 
diffuse  diseases  of  the  osseus  system,  such  as  osteo- 
malacia  and  disseminated  lesions  of  the  bone- 
marrow.  These  possibilities  must  therefore  always 
be  kept  in  mind. 


FUNCTIONAL   MODIFICATION  27 

2.  DISORDERS  OF  THE  CIRCULATORY  APPARATUS. — 
The  intimate  relationship  existing  between  the  vas- 
cular and  muscular  systems  has  as  a  result,  that  in 
disorders  both  of  the  central  and  peripheral  portions 
of  the  circulatory  system,  motion  may  appear  as  a 
potent  source  of  pain.  The  circulatory  system  is 
also  one  of  the  channels  through  which  the  physical 
and  objective  act  of  motion  transforms  itself  into 
the  subjective  sensation  of  pain.  Every  muscle, 
whether  it  is  striated  or  smooth,  when  in  action 
makes  increased  demands  on  the  vascular  system  as 
a  whole,  and  also  on  its  own  peripheral  district.  In 
this  way  it  is  easy  to  understand  on  the  one  hand 
the  possibility  of  the  causation  of  local  pain  on 
locomotion  in  local  disorders  (crural,  mesenteric,  and 
coronary  vessels),  and  on  the  other  hand  it  is  clear 
that  muscular  action  may  produce  pain  indepen- 
dently of  peripheral  demands  through  the  indirect 
effect  on  the  central  portions  of  the  circulatory  sys- 
tem, as  in  aortitis,  aneurysm,  etc.  It  is  therefore  an 
easily  explainable  fact  that  all  of  the  symptoms 
produced  by  aneurysms  or  chronic  inflammation  of 
the  aortic  walls,  and  especially  pain,  may  be  in- 
creased or  brought  about  by  bodily  motion.  If,  for 
example,  retrosternal  or  epigastric  pain  is  caused 
as  the  result  of  severe  muscular  exertion,  such  as 
climbing  stairs,  running,  or  battling  against  the 
wind,  the  possibility  of  the  presence  of  disease  of 
the  circulatory  system  must  always  be  suspected 
(atheroma  of  the  thoracic  and  abdominal  aorta,  scle- 
rosis of  the  coronary  arteries,  hepatic  congestion). 


28  PAIN 

The  same  is  true  in  regard  to  pain  in  the  shoulder, 
or  brachial  neuralgia  (aneurysm). 

3.  ABDOMINAL  DISOEDEKS. — In  these  there  is  not 
rarely  an  exquisite  interdependence  between  pain 
and  motion.  This  is  especially  true  of  acts  that  are 
accompanied  by  simultaneous  exercise  of  the  abdom- 
inal muscles,  such  as  lifting  weights,  stooping,  rais- 
ing the  head,  defecation,  backward  or  lateral  inclina- 
tion of  the  body,  coughing,  sneezing,  etc.  Undoubt- 
edly it  is  the  accompanying  elevation  of  intra- 
abdominal  pressure  that  gives  rise  to  the  painful 
paroxysms  in  already  congested  organs  (ureteral 
and  biliary  colic,  etc.),  either  directly  or  through 
the  interference  with  the  venous  flow.  Before  the 
onset  of  typical  attacks  of  pain  and  also  after  the 
subsidence  of  these  the  appearance  of  distinctly 
localized  pain  as  the  result  of  efforts  of  the  sort  just 
mentioned  may  direct  attention  to  a  local  disorder 
in  the  nature  of  latent  appendicitis  or  cholecystitis, 
etc.  Pain  in  the  neighborhood  of  the  appendix,  for 
example,  is  not  rarely  elicited  during  defecation, 
in  drawing  on  the  shoes,  lifting  the  head,  bending 
the  trunk  to  the  left,  on  sitting  down,  etc.  Pain  in 
the  epigastrium  on  bending  the  body  backward  would 
suggest  the  presence  of  an  epigastric  hernia. 

The  pain  produced  through  forcible  motion  at 
the  hip  joint  in  inflammatory  and  suppurative  proc- 
esses in  the  neighborhood  of  the  ileopsoas  muscle 
involving  the  appendix,  caecum,  kidney,  and  para- 
metrium  finds  its  explanation  in  the  local  pressure 
caused.  Under  these  conditions  it  is  important  not 


FUNCTIONAL   MODIFICATION  29 

to  make  the  examination  in  the  horizontal  position, 
in  which  the  abdominal  muscles  are  relaxed,  but  to 
have  the  patient  standing,  as  then  the  pressure 
effects  are  more  pronounced.  Of  course  it  is  also 
necessary  to  think  of  inflammatory  processes  involv- 
ing the  joint  itself.  The  pain  accompanying  certain 
movements  of  the  thigh  in  incarcerated  hernia  (ob- 
turator hernia)  must  not  be  overlooked  in  this  con- 
nection. The  jar  communicated  to  the  abdomen 
along  the  lower  extremity  on  putting  the  foot  to 
the  ground  may  give  rise  to  pain ;  for  example,  in  the 
neighborhood  of  an  inflamed  appendix,  a  movable 
kidney,  or  in  cholecystitis.  This  pain  appears  when 
the  foot  of  the  same  side  strikes  the  ground,  and 
is  more  pronounced  in  walking  down  hill  owing  to 
the  greater  force  of  the  concussion. 

THE  INFLUENCE  OF  PRESSURE. 
The  influence  of  pressure,  especially  pressure 
from  within,  is  of  great  importance  in  the  mech- 
anism of  spontaneous  attacks  of  pain.  An  elevation 
of  intracranial  pressure  gives  rise  to  most  severe 
headache.  A  rise  of  tension  in  the  arterial  system 
may  produce  extremely  painful  paroxysms;  in- 
crease in  the  internal  pressure  in  the  liver,  spleen, 
or  kidney  may  cause  acute  pain  through  the  tension 
of  the  capsule  of  the  organ,  and  the  same  thing  is 
true  of  localized  distention  in  the  gastro-intestinal 
canal. 

Pressure  from  without  exerted  for  the  purpose 
of  testing  a  painful  condition  is  usually  not  effective 


30  PAIN 

from  all  directions,  as  in  the  above  instances,  but 
only  from  a  given  point.  Nevertheless,  under  some 
conditions  spontaneous  pressure  effects  in  all  direc- 
tions may  be  experimentally  imitated  and  made  use 
of  for  differential  diagnosis ;  for  example,  in  dealing 
with  the  digestive  tract.  I  remember  one  case  in 
which  the  nature  of  a  tumor  below  the  left  costal 
arch  was  in  doubt  until  the  colon  was  inflated.  At 
once  pain,  localized  strictly  to  the  tumor  region,  ap- 
peared, and  at  the  autopsy  carcinoma  of  the  splenic 
flexure  of  the  colon  was  revealed.  In  a  similar  way 
in  cases  of  carcinoma  of  the  oesophagus  with  stenosis 
the  administration  of  effervescent  draughts  may 
give  rise  to  localized  pain,  evidently  caused  by  the 
tension  from  within. 

PRESSURE  FROM  WITHOUT. — When  applied  for 
diagnostic  purposes  this  may  be  used  in  order  to 
obtain  more  exact  information  in  regard  to  the 
location  of  already  existing  pain,  or  it  may  be  re- 
sorted to  to  discover  a  hitherto  unrevealed  area  of 
hyper  algesia.  In  doing  this  it  is  well  to  remember 
that,  even  under  physiological  conditions  and  accord- 
ing to  the  degree  of  individual  susceptibility,  strong 
pressure  may  be  more  or  less  painful,  and  it  is  advis- 
able always  to  compare  similar  areas  on  the  two 
sides.  It  is  further  desirable  always  to  outline  the 
zones  of  hyperaesthesia  to  pressure  as  accurately  as 
possible.  The  more  deeply  the  pressure  is  carried 
the  greater  is  the  loss  of  the  resulting  pain  in  local- 
izing value,  and  this  is  particularly  true  of  the 
abdominal  cavity. 


FUNCTIONAL  MODIFICATION  31 

PERCUSSION. — By  means  of  this  it  is  possible  to 
obtain  an  accurate  estimate  of  the  effect  of  pressure 
and  this  method  of  examination  should  never  be 
omitted,  especially  in  examining  the  abdomen.  Posi- 
tive results  will  generally  be  obtained  by  this  proce- 
dure in  dealing  with  organs  that  touch  the  abdomi- 
nal wall  with  even  only  a  portion  of  their  surfaces, 
as  the  stomach,  intestine,  liver,  and  spleen  in  the 
anterior  parts  and  the  kidney  in  the  posterior  parts. 
The  examination  of  the  linea  alba  in  this  way  for 
its  whole  length,  from  the  xiphoid  process  to  the 
symphysis,  is  especially  to  be  recommended.  If 
there  is  any  diastasis  of  the  recti,  pressure  or  per- 
cussion in  this  region  is  not  transmitted  through  the 
abdominal  musculature,  as  is  the  case  over  the  recti, 
but  causes  distinct  manifestations  of  pain  if  one 
of  the'  organic  lesions  in  question  is  present. 

In  general  it  may  be  said  that  at  every  examina- 
tion of  the  abdomen  for  purposes  of  rapid  orientation 
it  is  wise  to  test  the  sensibility  to  pressure  of  the 
region  of  the  pylorus  and  gall-bladder,  the  three 
.flexures  of  the  colon,  the  neighborhood  of  the  appen- 
dix, and  the  hernial  openings.  Any  local  sensitive- 
ness to  pressure  in  the  rectum  or  vagina  should  also 
be  noted.  The  testing  of  local  sensibility  to  pres- 
sure also  forms  a  useful  method  of  rapid  orientation 
in  cases  in  which  accurate  palpation  is  rendered 
impossible  owing  to  tension  of  the  abdominal  walls 
as  in  ascites. 

Among  the  pathological  processes  of  a  general 
nature  that  underlie  pressure  or  percussion  pain  in 


32  PAIN 

the  abdominal  region  the  first  place  must  be  given  to 
peritoneal  irritation,  either  circumscribed  or  diffuse. 
In  addition,  increase  in  the  internal  pressure  also 
plays  an  important  role;  for  example,  in  such  con- 
ditions as  hepatic  congestion,  and  circumscribed  or 
diffuse  gastro-intestinal  distention,  especially  when 
accompanied  by  ulcerative  or  peritonitic  lesions. 
Thus  the  hyperaesthesia  of  the  congested  liver  dimin- 
ishes in  proportion  to  its  decrease  in  size,  and  the 
tenderness  of  gastric  ulcer  may  decrease  from  an 
excessive  degree  to  a  very  slight  amount  within  a 
few  hours  owing  to  the  subsidence  of  gastric  disten- 
tion. The  sensitiveness  of  an  inflamed  appendix 
may  in  the  same  way  diminish  suddenly  on  the  expul- 
sion of  faeces  and  gas.  "While  in  most  cases  it  is 
natural  to  associate  any  existing  abdominal  tender- 
ness with  the  topographically  related  organs  the 
rarer  possibilities  must  also  be  kept  in  mind.  For 
example,  the  symptom  may  have  its  seat  in  the  ab- 
dominal musculature  itself,  as  in  the  epigastric 
tenderness  due  to  fatigue  of  the  origins  of  the  recti 
following  persistent  attacks  of  coughing.  If  the 
seat  of  the  pain  is  situated  behind  the  muscle  the 
contraction  of  the  latter  usually  diminishes  or  abol- 
ishes the  effect  of  the  pressure,  and  this  may  be  of 
value  in  differential  diagnosis.  The  vascular  system 
of  the  abdominal  cavity,  particularly  the  aorta,  may 
also  be  the  seat  of  tenderness  in  the  epigastrium. 
Furthermore,  the  possibility  of  neuralgic  tenderness 
of  the  sensory  tracts  should  not  be  forgotten,  as  in 
lead  colic,  gastric  crises,  etc.  Sometimes  in  abdom- 


FUNCTIONAL  MODIFICATION  33 

inal  neuralgias  of  this  sort  intense  pressure,  over 
the  epigastrium  for  example,  may  seem  to  have  the 
effect  of  relieving  pain.  This  sign  may  sometimes 
be  made  use  of  in  diagnosis,  though  caution  is  neces- 
sary, as  the  same  thing  exceptionally  occurs  in 
organic  diseases. 

I  am  inclined  to  consider  the  accurate  localiza- 
tion of  tenderness  of  the  sympathetic  nerve  fibres 
and  plexuses  running  deep  down  along  the  spinal 
column  as  theoretically  highly  desirable  but  prac- 
tically impossible,  and  the  same  thing  may  be  said 
in  regard  to  the  determination  of  tenderness  of  the 
solar  plexus. 

THE  INFLUENCE  OF  FOOD. 

While  the  importance  of  the  exact  determination 
of  the  alimentary  causation  or  modification  of  pain 
phenomena  is  very  great,  the  difficulties  attending 
the  demonstration  of  a  relationship  of  this  sort  are 
no  less  so.  This  is  especially  the  case  when  the 
evidence  consists  only  of  the  biased  or  inaccurate 
observations  of  the  patient  himself.  Frequently  the 
connection  between  the  two  events  is  denied  with  the 
statement  that  pain  is  present  also  when  food  is  not 
being  taken  and  that  the  composition  of  the  ingesta 
has  no  noticeable  effect.  It  is  evident  that  both  of 
these  conclusions  are  erroneous.  In  the  first  in- 
stance, it  is  permissible  to  draw  only  the  inference 
that  the  ingestion  of  food  is  not  the  only  pain-produc- 
ing factor,  and  in  the  second  that  the  quality  of  the 
food  is  of  slight  importance.  The  difficulty  of  estab- 


34  PAIN 

listing  a  relationship  of  cause  and  effect  is  also 
increased  through  the  fact  that  in  most  cases  the 
pain,  at  least  as  far  as  it  involves  the  gastro-intes- 
tinal  tract,  appears  only  several  hours  after  the 
ingestion  of  food. 

If  the  pain  begins  during  the  taking  of  the  food 
itself  a  deep-seated  stenosis  of  the  oesophagus,  par- 
ticularly carcinomatous,  should  be  thought  of  even 
in  the  absence  of  well-defined  dysphagia  and  though 
the  pain  be  localized  in  the  epigastrium.  The  pain- 
ful sensations  caused  by  the  food  masses  that  become 
impacted  above  the  stenosis  are  not  infrequently 
referred  to  the  epigastrium,  are  accompanied  by  a 
feeling  of  pressure,  and  usually  disappear  suddenly 
at  the  moment  that  the  bolus  passes  the  obstruction. 
Alimentary  modification  of  the  pain  is  ordinarily  to 
be  taken  for  granted  only  when  the  pain  follows  the 
ingestion  of  food  with  great  regularity  and  after  the 
lapse  of  a  uniform  interval  of  time.  In  these  cases 
it  is  always  advisable  to  determine  the  relationship 
experimentally  by  modifications  in  the  amount  and 
composition  of  the  food. 

The  ingestion  of  food  may  serve  to  produce  pain 
in  several  ways,  among  which  the  most  important  are 
as  follows: 

1.  The  increase  in  gastro-intestinal  peristalsis 
following  the  taking  of  food  may  serve  mechanically 
to  induce  pain.  In  this  connection  the  effect  of  cold 
appears  to  be  especially  noteworthy,  as  when  cold 
water  is  taken.  The  colicky  pain  sometimes  appear- 
ing in  acute  enteritis  or  appendicitis  a  short  time 


FUNCTIONAL   MODIFICATION  35 

after  a  drink  of  cold  milk,  for  example,  is  certainly 
caused  in  this  way.  When  inflammatory  ulceration 
exists  in  the  oesophagus,  pylorus,  intestine,  etc.,  it 
is  natural  to  assume  that  the  muscular  contrac- 
tions set  in  motion  for  the  purpose  of  carrying 
along  the  contents  of  the  viscus  form  the  cause  of 
the  pain,  so  that  it  is  easy  to  understand  that  the 
composition  of  the  food  itself  may  not  be  of  any 
particular  importance. 

2.  Chemical  stimuli  in  the  form  of  ingested  acids, 
spices,  etc.     The  decomposition  products  resulting 
from  bacterial  action  on  carbohydrates  and  fats  must 
also  be.  included  under  this  head. 

3.  Local  irritation  due  to  the  mechanical  action 
of  substances  like  hard  bits  of  meat  and  similar 
bodies,    distention    of    the    gastro-intestinal    wall 
through  the  formation  of  gas  due  to  the  fermentation 
of   farinaceous   foods,   fruits,   etc.     This   mode   of 
causation  seems  to  play  an  especially  important  role 
in  cases  of  gastro-intestinal  ulceration. 

The  factors  mentioned  above  have  a  positive 
action ;  that  is  to  say,  cause*  increase  in  pain,  but 
there  is  also  the  possibility  of  an  influence  in  the 
opposite  direction.  It  is  a  fact  that  not  only  in 
gastric  neuroses  but  also  in  cases  of  ulcer  and  some- 
times in  gastric  carcinoma  the  ingestion  of  food  may 
alleviate  or  entirely  relieve  previously  existing  pain. 
Two  possibilities  must  be  considered  in  this  connec- 
tion: 1.  The  excessive  and  painful  peristalsis  is 
relieved  by  the*  entrance  of  food  into  the  stomach 
(the  growling  of  a  hungry  stomach).  In  cases  in 


36  PAIN 

which  the  nature  of  the  food  seems  to  be  unimpor- 
tant, so  that  even  a  piece  of  bread,  for  example,  has 
an  anodyne  effect,  this  appears  to  be  the  most  nat- 
ural explanation.  2.  The  food  consumed,  such  as 
milk,  for  example,  combines  with  acid  after  the  fash- 
ion of  an  alkali. 

In  regard  to  the  time  of  appearance  of  alimen- 
tary pain  phenomena  the  variability  of  the  causes 
explains  the  differences  observed  in  the  period  of 
their  appearance,  although  in  the  same  individual 
the  time  intervals  in  cases  of  organic  disease  are 
often  very  uniform.  The  painful  attacks  attending 
lesions  of  the  pylorus,  for  example  benign  stenosis, 
appear  with  great  regularity  two  or  three  hours 
after  the  midday  meal,  probably  in  connection  with 
the  expulsive  period  of  digestion.  Cases  are  ob- 
served often  enough,  however,  in  which  the  interval 
is  as  much  as  five  or  six  hours.  I  consider  that 
attempts  to  draw  inferences  from  such  observations 
regarding  the  position  of  the  lesion,  for  example, 
that  it  is  a  duodenal  ulcer,  are  entirely  unwarranted. 
On  the  one  hand  the  appearance  of  the  pain  of 
pyloric  ulcer  may  be  much  delayed  as  has  been  men- 
tioned, and  on  the  other,  in  duodenal  ulcer  and  intes- 
tinal affections  including  those  of  the  colon  (cancer 
of  the  sigmoid  flexure,  appendicitis,  etc.),  the  pain 
may  be  felt  a  very  short  time  after  the  food  has  been 
taken.  It  is  interesting  that  in  some  cases  of  pyloric 
ulcer  the  onset  of  the  pain  is  delayed  if  the  quantity 
of  food  taken  is  very  large.  This  is  probably  due 
to  the  fact  that  the  expulsion  of  the  gastric  contents 


FUNCTIONAL  MODIFICATION  37 

is  retarded.  When  there  is  a  clearly  demonstrable 
connection  between  the  ingestion  of  food  and  the 
pain,  internal  gastro-intestinal  lesions,  especially 
those  of  an  ulcerative  and  stenotic  character,  must 
be  thought  of.  In  addition,  the  somewhat  rarer 
perigastritic  processes  should  be  kept  in  mind,  such 
as  adhesions  between  stomach  and  liver  in  syphilis 
of  the  latter  organ,  adhesions  between  stomach  and 
colon  in  carcinoma  of  the  splenic  flexure,  etc.  En- 
largement of  the  organs  in  the  neighborhood  of  the 
stomach  must  also  be  considered,  such  as  echino- 
coccus  of  the  liver  or  spleen,  pancreatic  cysts,  etc., 
but  these  lesions  are  more  apt  to  be  accompanied  by 
a  sensation  of  uncomfortable  pressure  rather  than 
by  direct  pain. 

Organic  lesions  are  particularly  likely  to  be  pres- 
ent in  cases  in  which  there  are  no  fluctuations  in  the 
intensity  of  the  symptoms,  in  which  the  effect  of 
psychical  factors  is  slight  or  entirely  absent,  and  the 
alimentary  factor  is  characterized  by  great  consist- 
ency. Owing  to  the  close  interrelationship  between 
the  gastro-intestinal  tract  and  the  large  abdominal 
glands,  the  liver  and  pancreas,  it  is  natural  to  expect 
a  priori  that  on  account  of  the  circulatory  changes 
in  these  organs  attending  the  digestive  act  pain 
from  these  districts  also  should  be  subject  to  alimen- 
tary modification.  Such  interdependence  is  very 
irregular  in  its  manifestation,  however,  and  fre- 
quently cannot  with  certainty  be  demonstrated  at 
all.  Equally  irregular  is  the  alimentary  relation- 
ship of  the  pain  often  observed  after  the  subsidence 


38  PAIN 

of  lead  colic  or  gastric  crises.  In  the  former  con- 
dition painful  attacks  are  not  rarely  the  result  of 
a  diet  that  tends  to  gas  formation. 

Pain  resulting  from  disease  of  the  circulatory 
system  is  also  susceptible  of  modification  by  the  in- 
gestion  of  food,  as  will  appear  later.  Attacks  of 
angina  pectoris  may  follow  meals  excessive  in 
amount  or  composed  of  food  causing  gastric  and 
intestinal  distention.  The  phenomenon  may  prob- 
ably be  explained  in  part  by  the  rise  in  blood  pres- 
sure and  increased  demand  upon  the  heart.  The 
influence  of  food  ingestion  may  also  be  observed  in 
cases  of  atheroma  involving  the  gastro-intestinal 
vessels. 

THE  INFLUENCE  OF  DRUGS  AND  CHEMICALS. 

All  forms  of  pain  exhibit  a  widespread  suscepti- 
bility to  modification  by  the  administration  of  drugs, 
quite  independently  of  the  effects  of  the  narcotics. 
Furthermore,  there  may  be  in  some  cases  a  specific 
susceptibility  obviously  depending  on  more  or  less 
fundamental  factors  in  the  mechanism  of  production 
of  the  pain  in  question,  and  which  may  be  made  use 
of  for  the  purposes  of  differential  diagnosis.  It  is 
well  known  with  what  regularity  the  paroxysms  of 
angina  pectoris  respond  to  the  administration  of  the 
vasodilators.  For  this  purpose  I  should  especially 
recommend  erythrol  tetranitrate  in  the  form  of  pills 
containing  0.01  g.  each.  In  a  case  presenting  indefi- 
nite pain  in  the  neighborhood  of  the  heart  or  in  the 
epigastrium  and  where  there  are  other  reasons  for 


39 

suspecting  vascular  disease,  the  resort  to  an  erytlirol 
tetranitrate  test  may  be  of  great  diagnostic  value, 
especially  if  the  effect  is  more  or  less  sudden  and 
the  same  result  always  follows  a  repetition  of  the 
test.  Obscure  neuralgic  pains  in  the  left  upper 
extremity  may  also  be  unmasked  in  this  way  and  be 
found  to  depend  on  an  irregular  form  of  angina. 
Reflex  pain  of  this  sort  in  the  upper  extremity 
is  sometimes  relieved  by  the  application  of  cold 
to  the  precordium. 

Local  anaesthetics  may  be  used  for  the  purposes 
of  differential  diagnosis  in  order  to  determine 
whether  the  cause  of  the  pain  is  peripheral  or  cen- 
tral. The  subcutaneous  injection  of  cocaine  has 
been  recommended  for  this  purpose  in  trigeminal 
neuralgia  and  a  5  per  cent,  ointment  of  morphine 
has  been  used  with  a  similar  object.  In  testing  the 
gastric  mucosa  the  use  of  ansesthesin  in  0.5  g.  doses, 
or  of  cocaine  (about  16  drops  of  a  1  per  cent,  solu- 
tion), may  be  recommended.  The  pain  of  gastric 
ulcer  or  of  ulcerating  carcinoma  of  the  oesophagus 
usually  ceases  within  about  a  quarter  of  an  hour 
after  the  administration  of  these  amounts  of  anaes- 
thesin  or  cocaine.  If  this  occurs  in  a  case  under 
consideration,  duodenal  ulcer  is  improbable,  and  I 
therefore  suggest  this  anaesthesin  test  as  a  means  of 
differential  diagnosis  between  gastric  and  duodenal 
ulceration.  A  prompt  result  following  the  anaes- 
thesin treatment  in  cases  of  epigastralgia  usually 
indicates  a  lesion  of  the  gastric  mucosa  such  as  ulcer 
or  carcinoma  and  justifies  the  assumption  of  a  local 


40  PAIN 

causation  of  the  pain.  If  the  pain  is  accompanied 
by  evidences  of  stenosis,  such  as  increased  gastric 
peristalsis  or  dysphagia,  a  positive  result  of  the  test 
would  point  to  internal  stenosis  with  changes  in  the 
mucous  membrane. 

In  order  to  decide  the  question  whether  a  gastric 
pain  is  partly  or  entirely  caused  by  hyperaesthesia 
to  hydrochloric  acid  this  may  be  given  while  fast- 
ing in  doses  of  1-5  drops  of  the  dilute  acid  to  a 
tablespoonful  of  water.  The  administration  of 
alkalis  such  as  sodium  bicarbonate  forms  a  pendant 
to  this  test.  It  must  be  borne  in  mind,  however, 
that  sodium  bicarbonate  may  bring  relief  and  ces- 
sation of  pain  by  causing  the  stomach  to  expel  any 
gas  that  may  be  present.  Epigastric  tenderness  due 
to  hepatic  congestion  is  usually  very  amenable  to 
digitalis  treatment.  If  it  shows  a  tendency  to  in- 
crease while  the  other  evidences  of  congestion  sub- 
side the  complication  of  gastric  ulcer  must  be  sus- 
pected (ulcer  in  a  congested  stomach). 

The  rapid  relief  of  headache  or  neuralgic  pain 
by  the  administration  of  iodine  and  mercury  of 
course  suggests  syphilis.  In  cases  of  headache,  tri- 
geminal  neuralgia,  sciatica,  etc.,  accompanied  by  con- 
stipation, it  is  advisable  to  resort  to  purgation  in 
endeavoring  to  obtain  insight  into  the  etiology  of 
the  pain.  While  the  intestinal  condition  is  not  very 
frequently  the  sole  cause  of  the  pain,  there  is  no 
doubt  that  it  sometimes  is  an  important  factor,  and 
the  diagnostic  and  therapeutic  aims  may  be  united. 
In  gastric  ulcer,  the  colic  of  pyloric  stenosis,  lead 


FUNCTIONAL  MODIFICATION  41 

colic,  etc.,  an  important  role  in  the  pain  formation 
is  often  played  by  stagnation  of  the  fecal  masses. 
Paroxysms  of  abdominal  pain  of  the  most  varied 
nature  (gall  passages,  ureters,  etc.)  frequently  re- 
spond very  directly  to  the  cautious  evacuation  of  the 
intestine  either  through  cathartics  given  by  mouth 
or  through  the  rectum. 

The  hypodermic  injection  of  distilled  water  may 
be  of  diagnostic  value  in  obscure  pain,  especially  in 
cases  in  which  the  patient's  suffering  is  completely 
or  in  part  the  result  of  autosuggestion.  Even  if 
the  pain  diminishes  there  is  always  the  possibility 
that  in  addition  to  the  functional  element  there  is 
also  an  organic  causative  factor,  and  in  this  way  it  is 
possible  to  form  an  idea  of  the  intensity  of  the  latter. 
Obscure  pain  about  the  thorax  (shoulder,  interscapu- 
lar  space,  etc.)  which  is  increased  by  the  injection 
of  tuberculin  probably  is  related  to  an  underlying 
tuberculous  process. 

THE  INFLUENCE  OF  ORGANIC  FUNCTION. 

The  coincidence  of  certain  pain  phenomena  with 
one  or  another  organic  function  may  form  the  start- 
ing point  of  a  diagnostic  analysis.  Sometimes  such 
a  conjunction  may  afford  appreciable  assistance,  but 
it  must  be  confessed  that  often  there  is  danger  of 
its  leading  into  error. 

DEFECATION. — The  act  of  defecation,  for  example, 
may  exhibit  the  most  varied  relationships  to  pain 
phenomena  of  widely  differing  origin.  Coprostasis 
of  long  .duration  causes  stagnation  and  abnormal 


42  PAIN 

decomposition  in  the  entire  digestive  tract,  includ- 
ing the  stomach,  and  it  is  not  surprising,  therefore, 
that  the  pain  accompanying  many  gastro-intestinal 
conditions,  such  as  appendicitis,  intestinal  stenosis, 
lead  poisoning,  ulcer,  stenosis  of  the  pylorus, 
etc.,  may  be  favorably  affected  by  the  cautious 
production  of  an  evacuation,  a  fact  which  de- 
serves careful  consideration  from  the  standpoint 
of  therapeutics  also.  In  dealing  with  inflammatory 
lesions  in  the  abdomen  care  must  be  taken,  however, 
that  the  act  of  defecation  does  not  involve  too  great 
a  degree  of  exertion  of  the  abdominal  musculature. 
Otherwise  precisely  during  the  act  of  defecation 
strictly  localized  pain  may  be  caused  corresponding 
to  the  position  of  the  inflamed  appendix  or  diseased 
gall-bladder,  or  in  the  neighborhood  of  a  carcinoma 
of  the  colon  or  gastric  ulcer.  Such  an  occurrence 
may  have  diagnostic  value  in  determining  the  posi- 
tion of  the  process  in  question.  This  localized  pain, 
accompanying  abdominal  straining,  may  be  spoken 
of  by  the  patient  and  be  of  assistance  in  the  diag- 
nosis in  cases  of  quiescent  appendicitis,  or  on  the 
other  hand,  in  the  early  stages  of  the  disease.  Back- 
ache resulting  from  gastro-intestinal  distention  (in- 
testinal stenosis,  etc.)  is  usually  perceptibly  relieved 
after  a  movement  of  the  bowels.  If  the  movement  is 
regularly  preceded  by  pain  immediately  before  the 
act,  deep-seated  ulcerative  processes  such  as  carci- 
noma of  the  rectum  should  be  suspected. 

In  cases  of  latent  angina  pectoris  severe  abdom- 
inal straining  during  defecation  may  cause  the  onset 


FUNCTIONAL   MODIFICATION  43 

of  a  paroxysm,  or  slight  retrosternal  premonitory 
sensations  may  be  induced.  The  favorable  effect  of 
defecation  is  often  indubitable  and  even  astonishing 
in  many  cases  of  headache,  especially,  it  appears 
to  me,  in  those  types  which  are  accompanied  by 
an  elevation  of  intracranial  pressure.  A  laxative 
frequently  is  much  more  effective  than  large  doses 
of  antineuralgics,  even  in  cases  of  severe  organic 
lesions  like  brain  tumors.  In  these  cases  the  im- 
provement must  depend  on  alterations  in  the  intra- 
cranial circulation,  for  the  effect  is  often  very  sud- 
den. Meteorism  may  lead  to  stasis  in  the  superior 
vena  cava  and  in  the  cerebral  veins  through  the 
restriction  of  the  respiratory  venous  aspiration,  and 
the  important  part  played  by  normal  intestinal  peri- 
stalsis in  facilitating  the  venous  circulation  in  the 
portal  district  must  also  be  considered.  In  these 
cases,  too,  the  act  of  defecation  may  give  rise  to 
temporary  increase  in  the  headache  if  it  is  accom- 
panied by  undue  straining  efforts. 

The  onset  of  gastric  crises  in  tabes  not  rarely 
occurs  in  conjunction  with  defecation  and  the  evacu- 
ation of  fluid  stools.  It  is  likely,  however,  that  the 
act  of  defecation  is  in  these  cases  only  indirectly  to 
be  associated  with  the  gastric  symptoms  (increased 
gastro-intestinal  peristalsis).  In  enteroptosis,  in- 
testinal atony  and  neuropathic  conditions  persistent 
constipation  sometimes  appears  rather  to  have  the 
effect  of  deferring  the  onset  of  functional  pains, 
such  as  gastralgias. 


44  PAIN 

VOMITING. — If  vomiting  accompanies  abdominal 
pain  the  coincidence  of  the  latter  with  this  common 
symptom  is  more  apt  to  lead  astray  than  to  be  of 
direct  diagnostic  service,  unless  it  happens  that  the 
nature  of  the  vomitus  (blood,  sarcinae,  lactic  acid 
bacilli,  hyperchlorhydria,  etc.)  gives  the  necessary 
clue.  One  may  easily  be  deceived  by  the  vomiting 
in  chronic  intestinal  stenoses,  for  example  in  tu- 
berculous ulceration  of  the  small  intestine,  and  in 
the  absence  of  peristaltic  movement  be  led  to 
assume  a  gastric  lesion  such  as  stenosis  of  the 
pylorus  as  the  starting  point  of  the  pain.  Slight 
alleviation  of  the  pain  after  vomiting  is  sometimes 
observed  in  painful  seizures  of  the  most  varied 
nature,  such  as  angina  pectoris,  renal  infarct,  chole- 
lithiasis, etc.  Prompt  and  often  complete  relief  to 
the  pain  is  particularly  characteristic  of  attacks  of 
colic  due  to  stenosis  of  the  pylorus. 

DEGLUTITION. — Pain  accompanying  the  act  of 
swallowing  may  depend  on  internal  or  external 
causes.  If  the  source  of  the  sensation  is  in  the 
upper  part  of  the  oesophagus  its  detection  will  ordi- 
narily not  prove  difficult.  If  the  patient  has  fever  the 
possible  existence  of  laryngeal  tuberculosis  should 
not  be  forgotten.  If  the  dysphagia  is  due  to  ulcer- 
ation of  some  portion  of  the  cesophageal  mucosa  an 
increase  in  the  pain  is  usually  caused  on  taking  acids 
or  spiced  articles  of  food.  On  the  other  hand,  the 
administration  of  local  anaesthetics  like  anaesthesin 
will  prove  beneficial.  This  effect  of  food  or  drugs 
is  generally  absent  if  there  are  other  causes  for  the 


FUNCTIONAL   MODIFICATION  45 

disturbance  in  deglutition,  unless  secondary  ulcera- 
tions  have  been  caused.  The  deglutition  pain  of 
aneurysm  frequently  radiates  into  the  left  shoulder 
or  below  the  clavicle. 

MENSTKTJATION. — While  it  is  natural  to  refer  to 
the  genital  apparatus  pains  occurring  together  with 
menstruation — or  at  least,  if  they  involve  regions  at 
a  distance  such  as  headache  or  gastralgia,  to  asso- 
ciate them  with  this  function — it  must  always  be 
borne  in  mind  that  the  menstrual  process  leads  to 
increased  irritability  of  the  system  in  general. 
Therefore,  whenever  there  is  already  present  an 
irritative  condition,  such  as  cholelithiasis,  appen- 
dicular  disease,  ulcer  of  the  stomach,  etc.,  attacks  of 
pain  may  be  brought  on  in  these  regions  of  lessened 
resistance.  This  is  especially  true  of  the  appendix, 
owing  to  its  topographical  relationships  and  its 
circulatory  connections.  In  distinction  to  this  many 
obstinate  abdominal  pains  such  as  gastralgias  seem 
to  be  checked  during  pregnancy.  This  is  particu- 
larly the  case  in  enteroptosis,  probably  in  part  owing 
to  the  diminution  of  the  abnormal  mobility  of  the 
abdominal  organs. 

EESPIKATION. — In  dealing  with  shoulder  pains  in- 
duced by  respiration,  it  is  always  advisable  to  think 
of  the  possible  presence  of  apical  tuberculosis  with 
secondary  perineuritis  of  the  brachial  plexus  (ten- 
derness on  pressure).  Pain  in  the  domain  of  the 
thoracic  muscles  may  of  course  be  purely  myogenic 
in  nature  in  spite  of  its  dependence  on  the  respira- 
tory act.  The  retrosternal  pain  sometimes  produced 


46  PAIN 

by  deep  respiration  in  cases  of  atheroma  of  the  aorta 
may  be  explained  by  the  traction  on  the  vessel. 
Both  local  and  diffuse  peritonitic  lesions  such  as 
perihepatitis,  perigastritis,  etc.,  as  well  as  lesions 
of  movable  abdominal  viscera  in  general,  are  fre- 
quently the  seat  of  pain  on  sudden  inspiratory  dislo- 
cation, especially  that  caused  by  diaphragmatic 
breathing. 


CHAPTER  III. 

TOPOGRAPHY  IN  ITS  EELATION  TO  PAIN. 

WHILE  in  external  diseases  the  site  of  pain  nearly 
always  corresponds  to  tne  lesion,  this  is  true  of 
internal  affections  only  with  certain  reservations 
and  in  this  connection  there  is  found  an  unending 
source  of  diagnostic  errors.  Even  the  general  ques- 
tion of  whether  the  presence  of  local  pain  indicates 
the  existence  of  any  disease  of  an  internal  organ  and 
is  not  due  to  an  external  lesion,  may  sometimes  be 
difficult  to  answer.  Before  arriving  at  the  conclu- 
sion that  a  certain  painful  sensation  is  caused  by 
internal  disease,  it  will  be  found  practically  useful 
to  exclude  the  possibility  of  an  affection  of  the 
organs  of  motion — joints,  muscles,  or  bones- — as  well 
as  of  disorders  of  the  nervous  system  (v.  Neural- 
gias). The  patient's  own  sensations  and  his  de- 
scription of  the  pain  as  being  deep  seated  may  some- 
times, but  not  always,  point  to  the  existence  of  an 
internal  lesion. 

The  following  discussion  of  pain  in  connection 
with  topography  will  be  devoted  only  to  those  mani- 
festations that  are  the  result  of  disease  of  the  inter- 
nal organs.  The  inclusion  of  disorders  of  the 
organs  of  motion  and  of  the  nervous  system  would 
lead  too  far  afield.  Even  with  this  restriction,  how- 
ever, completeness  of  exposition  is  out  of  the  ques- 
tion and  therefore  only  certain  districts  of  the  body 

47 


48  PAIN 

will  be  considered,  which,  may  be  regarded  as  nodal 
points  for  painful  sensations  emanating  from  dif- 
ferent directions.  The  obvious  will  be  omitted  and 
only  more  unusual  and  easily  overlooked  phenomena 
will  be  discussed,  particularly  from  the  therapeutic 
standpoint.  For  the  purposes  of  practical  differen- 
tial diagnosis  it  will  not  do  to  hold  too  closely  to 
purely  topographical  considerations.  It  is  espe- 
cially desirable  to  study  the  factors  that  influence 
the  pain;  that  is  to  say,  the  examination  must  in- 
clude a  test  of  function  as  well  as  of  the  accompany- 
ing symptoms,  as  has  already  been  pointed  out  in 
detail  in  the  section  on  the  analysis  of  pain.  In  the 
following  pages  I  will  be  as  brief  as  possible,  as  a 
more  detailed  discussion  of  the  various  organic  pains 
may  be  found  in  the  chapters  devoted  to  each  of 
these. 

I.  THE  SHOULDER. 

The  internal  organs  coming  in  question  under 
this  head  are  as  follows : 

a.  Lung. — Affections  of  the  pulmonary  apices, 
especially  tuberculosis  and  new  growths,  not  infre- 
quently cause  spontaneous  shoulder  pain  as  well  as 
tenderness  of  the  brachial  plexus,  probably  through 
the  development  of  perineuritis  or  direct  involve- 
ment of  the  branches  of  the  plexus.  I  have  found 
that  tenderness  is  particularly  apt  to  occur  at  the 
junction  of  the  outer  and  middle  thirds  of  the  upper 
border  of  the  trapezius.  TVTien  pain  in  the  shoulder 
is  complained  of  by  persons  of  tuberculous  appear- 
ance this  possibility  should  be  kept  in  mind. 


TOPOGRAPHY  49 

b.  Thoracic  Aorta. — Aneurysm  and  atheroma  of 
the  thoracic  aorta  not  infrequently  are  accompanied 
from  the  very  first  by  persistent  shoulder  pain. 
This  may  be  either  bilateral  or  only  on  one  side. 
In  addition  to  spontaneous  pain  there  is  frequently 
also  tenderness  over  the  brachial  plexus  as  well  as 
in  the  upper  intercostal  spaces  in  front.    Of  great 
diagnostic  importance  is  the  fact  that  the  pain  is 
increased  by  exertion,  such  as  stair  climbing,  etc., 
as  well  as  its  coincidence  with  increased  heart  action. 
Quieting  cardiac  activity  by  bodily  rest  and  the 
application  of  cold  compresses  generally  relieves 
this  aortic  shoulder  pain.    Motion  at  the  shoulder 
joint  may  be  free  and  painless,  but  lifting  the  upper 
arm  from  the  side  above  the  horizontal  line  is  likely 
to  evoke  pain  (traction  on  the  subclavian  artery?). 
It  must  be  remembered  that,  especially  in  athero- 
matous  disease  of  the  subclavian  artery  and  in  cases 
of  the  arthritic  diathesis,  aneurysm  of  the  aorta  and 
chronic  aortitis  may  coexist  with  more  or  less  inde- 
pendent disease  of  the  shoulder  joint  (rheumatic 
joint  lesions). 

c.  Subdiaphragmatic      Organs.  —  Inflammatory 
processes  occurring  in  the  liver,  spleen,  or  stomach, 
or    in    their    subphrenic    surroundings.     Shoulder 
pains  transmitted  in  this  way  through  the  phrenic 
nerve  of  the  same  side  usually  do  not  attain  particu- 
lar intensity.     The  causative  lesion,  such  as  echino- 
coccus  of  the  liver,  subphrenic  suppuration,  peri- 
splenitis  in  leukaemic  spleens,  perigastritis  in  ulcer 
of  the  stomach,  etc.,  ordinarily  causes  much  more 

4 


50  PAIN 

acute  local  symptoms,  so  that  if  the  possibility  of 
this  connection  is  kept  in  mind  the  danger  of  misin- 
terpreting the  shoulder  pain  is  not  very  great.  The 
shoulder  pain  may  sometimes  be  latent  and  appear 
only  on  pressure  on  the  brachial  plexus  or  on  the 
above-mentioned  pressure  point  at  the  upper  edge 
of  the  trapezius. 

II.  RETROSTERNAL  REGION. 

a.  Circulatory    Apparatus. — The    pain    accom- 
panying such  affections  as  aortic  aneurysm,  chronic 
aortitis,  and  sclerosis  of  the  coronary  arteries,  which 
are  the  ones  most  often  concerned  under  this  head- 
ing, is  accompanied  by  a  pronounced  sense  of  con- 
striction, and  has  the  further  peculiarity  of  being 
promptly  influenced  and  increased  on  exertion  such 
as  running,  climbing  stairs,  etc.     The  very  intense 
retrosternal  pain  that  is  sometimes  seen  in  cases  of 
pericarditis  is  not  paroxysmal  but  is  persistent. 

b.  Mediastinum. — Bifurcation  of  the  trachea  and 
local  affections  of  the  mediastinum.     The  retroster- 
nal pain  often  accompanying  the  cough  in  acute 
bronchitis  is  usually  to  be  explained  by  the  inflam- 
matory condition  at  the  bifurcation  of  the  trachea. 
In  some  cases  similar  changes  in  the  neighboring 
lymph  glands  may  contribute  to  its  causation.     The 
more  or  less  severe  and  persistent  retrosternal  pain 
not  rarely  accompanying  severe  dyspnoea  of  long 
duration  may  have  a  similar  origin,  and  I  have  found 
this  symptom  a  not  infrequent  accompaniment  in 
cases    of    miliary    tuberculosis.    Mediastinal    new 


TOPOGRAPHY  51 

growths,  such  as  lymphosarcoma,  etc.,  also  not  infre- 
quently cause  retrosternal  pain  that  may  be  relieved 
to  some  extent  by  leaning  forward  (transfer  of  the 
pressure  to  the  sternum  and  relief  of  the  more  sensi- 
tive posterior  structures).  Such  pain  may  be  in- 
creased by  rapid  walking,  etc.,  probably  through 
the  forced  inspiration  and  consequent  increase  in  the 
motility  of  the  trachea  and  traction  on  the  surround- 
ing structures.  This  observation  may  lead  to  the 
erroneous  diagnosis  of  angina  pectoris. 

c.  (Esophagus,  Stomach,  and  Liver. — Fairly  se- 
vere retrosternal  pain  may  be  due  to  stretching  of 
the  wall  of  the  oesophagus  on  taking  food  if  the  lower 
portion  of  the  tube  is  stenosed.  Pain  of  this  nature 
exhibits  extreme  dependence  on  alimentary  condi- 
tions. Retrosternal  radiation  of  the  pain  is  not 
rare  in  ulcer  of  the  stomach  and  pyloric  stenosis, 
although  in  these  conditions  the  pain  is  rarely  found 
only  in  this  situation.  The  same  thing  is  true  of 
hepatic  affections. 

In  the  preceding,  retrosternal  sensations  have 
been  considered  only  in  so  far  as  they  reach  the 
point  of  actual  pain.  Sensations  such  as  the  feel- 
ing of  oppression  sometimes  occurring  in  nervous 
asthma,  tuberculosis,  dilatation  of  the  right  heart, 
or  tabes,  are  not  within  the  limits  of  the  discussion. 

III.  THE  SCAPULA  AND  INTERSCAPULAR  REGION. 

More  than  in  any  other  part  of  the  body  pain  in 
this  district  suggests  the  possibility  of  disease  of 
the  organs  of  motion  (spinal  column,  dorsal  muscles) 


52  PAIN 

as  well  as  neuralgia.  Only  after  these  have  been 
excluded  or  on  the  demonstration  of  corresponding 
organic  lesions  is  it  justifiable  to  consider  the  latter 
as  being  responsible  for  the  pain.  In  general  the 
possibilities  are  the  same  as  those  relating  to  shoul- 
der pains,  and  here  also  pulmonary  affections 
like  tuberculosis  are  not  unimportant.  Sometimes 
chronic  inflammatory  changes  in  the  pleura  leading 
to  the  formation  of  adhesions  or  glandular  changes, 
acting  like  the  retroperitoneal  glands  in  causing 
backache,  may  manifest  themselves  subjectively  by 
interscapular  pain.  Secondary  neuralgic  conditions 
of  the  intercostal  nerves  must  also  be  thought  of; 
at  any  rate  pains  of  this  sort  always  indicate  an 
exhaustive  examination  of  the  lung. 

Aortic  lesions  (aneurysm,  chronic  aortitis)  also 
not  rarely  give  rise  to  pain  in  the  interscapular 
region,  especially  on  the  left  side.  Frequently  there 
is  also  a  feeling  of  painful  pressure  and  sometimes 
a  dependence  on  particular  positions  of  the  body. 
A  priori,  an  increase  in  such  pain  is  to  be  expected 
on  exertion.  The  intimate  relationship  of  the  liver 
and  gall-bladder,  spleen,  and  stomach  to  the  shoulder 
blades  of  the  same  side  is  well  known,  and  reference 
may  be  made  to  what  has  been  said  above. 

Of  gastric  disorders  it  is  particularly  stenosis 
of  the  pylorus  that  gives  rise  to  painful  attacks  with 
radiation  into  the  left,  or  more  frequently,  both 
shoulder  blades.  This  radiation  of  the  pain  seems 
to  some  extent  to  run  parallel  with  the  intensity  of 
the  distention  of  the  stomach  during  the  paroxysm. 


TOPOGRAPHY  53 

The  shoulder  pains  previously  described  repre- 
sent a  spatial  prolongation  of  the  radiation  which 
ordinarily  rarely  passes  upward  beyond  the  spine 
of  the  scapula.  It  may  also  be  mentioned  that  the 
radiation  of  headache  into  the  interscapular  space  is 
generally  associated  with  an  increase  in  intracranial 
pressure,  as  in  brain  tumor,  meningitis,  etc. 

IV.  THE  EPIGASTRIUM. 

The  series  of  organic  lesions  manifesting  them- 
selves through  pain  in  the  epigastrium  is  so  great 
that  from  the  standpoint  of  practical  differential 
diagnosis  it  seems  more  suitable  in  each  case  to 
abandon  promptly  the  purely  topographical  factor 
and  to  turn  the  attention  to  certain  characteristic 
features  of  each  type  of  epigastralgia,  such  as  those 
comprised  in  the  modifying  factors,  accompanying 
manifestations,  etc.  In  this  way  more  rapid  orien- 
tation is  possible  and  the  diagnostic  possibilities  may 
rapidly  be  narrowed.  Here  again,  as  was  pointed 
out  at  the  beginning  of  the  chapter,  lesions  of  the 
organs  of  motion,  such  as  the  muscular  pain  follow- 
ing persistent  cough,  muscular  haematoma,  etc.,  and 
diseases  directly  concerning  the  nervous  system,  like 
the  neuralgia  of  spondylitis,  the  girdle  pains  of 
tabes,  or  gastric  crises,  will  not  be  discussed  at 
length. 

The  most  important  differential  points  to  be  dis- 
cussed are  as  follows : 

a.  Tenderness  to  Pressure  and  Percussion. — It  is 
true  that  most  of  the  spontaneous  pains  in  this  dis- 


54  PAIN 

trict  are  accompanied  by  tenderness  to  pressure,  but 
the  exact  localization  of  this,  and  particularly  the 
determination  of  the  point  of  maximum  tenderness, 
may  be  of  importance.  This  is  true,  for  example, 
for  the  tender  gall-bladder  in  cholelithiasis,  pain  on 
pressure  under  the  left  costal  arch  in  gastric  ulcer 
or  carcinoma,  or  in  syphilis  of  the  left  lobe  of  the 
liver,  sharply  circumscribed  tenderness  in  ulcer  and 
epigastric  hernia,  the  relation  of  the  sensitive  point 
to  the  edge  of  the  liver,  and  so  on.  The  absence  of 
tenderness  in  spontaneous  attacks  of  pain  would 
suggest,  though  not  without  reservation,  the  diag- 
nosis of  gastric  crises,  essential  gastralgia,  or  lead 
colic.  Its  presence,  however,  is  not  sufficient  to 
exclude  the  latter  affection. 

b.  Colic. — In  addition  to  the  common  paroxysms 
of  biliary  colic  and  gastralgia,  such  conditions  as 
intestinal  stenosis,  new  growths  of  the  small  intes- 
tine, tuberculous  intestinal  ulceration,  etc. — as  well 
as    particularly    appendicular    disease,    pancreatic 
colic,  and  angina  pectoris — must  also  be  considered. 

c.  Collapse. — The  evidences  of  collapse  may  ap- 
pear at  the  acme  of  any  attack  of  colic,  but  such 
severe  general  symptoms  are  especially  suggestive 
of  perforation,   as  in   gastric   or   duodenal   ulcer, 
acute  intestinal  obstruction,  gastric  crises,  pancre- 
atic necrosis,  and  angina  pectoris. 

d.  Causation  through  the  Ingestion  of  Food. — 
Under  this  heading  may  be  included  gastro-intes- 
tinal  lesions,  processes  in  the  neighborhood  of  the 
stomach    accompanied  by  progressive  increase  in 


TOPOGRAPHY  55 

size,  such  as  echinococcus  of  the  liver,  splenic  tumor, 
deep-seated  stenoses  of  the  oesophagus,  and  more 
rarely,  angina  pectoris  and  cases  of  painful  intermit- 
tent dilatation  of  the  abdominal  aorta. 

e.  Causation   through  Exertion. — In   this   class 
may  be  grouped  diseases  of  the  circulatory  appa- 
ratus, like  sclerosis  of  the  coronary  arteries  and 
chronic  aortitis.     The  sensation  of  painful  pressure 
due  to  hepatic  congestion  of  course  is  also  consid- 
erably increased  on  motion. 

f .  Position. — The  existence  of  a  position  of  maxi- 
mum pain  (v.  p.  22)  generally  may  be  taken  as  indi- 
cating an  organic  origin  for  the  symptom. 

g.  The  Influence  of  Drugs  (v.  p.  38). — This  con- 
cerns particularly  the  internal  administration   of 
local  anaesthetics,  of  hydrochloric  acid  and  alkalies, 
as  well  as  of  erythrol  tetranitrate. 

Of  much  more  importance  than  localization  in  the 
epigastrium  is  the  determination  of  asymmetrical 
distribution  of  the  pain.  If  this  is  more  manifest 
on  the  right  or  the  left,  either  spontaneously  or  on 
pressure,  an  organic  condition  is  a  priori  more  likely. 

A.  Localization  on  the  Right  Side. — Below  the 
right  costal  arch :  Spontaneous  pain  and  tenderness 
in  disease  of  the  gall-bladder,  of  the  pylorus,  the 
duodenum  (ulcer!),  the  hepatic  flexure  of  the  colon, 
as  in  carcinoma  or  flatulence,  renal  infarct,  etc.    In 
appendicular  disease  the  tenderness  is  usually  lower 
down;  in  pleurisy  and  pneumonia  of  the  lower  lobe 
there  is  usually  only  tenderness. 

B.  Localization  on  the  Left  Side. — Below  the  left 


56  PAIN 

costal  arch:  Here  both  in  spontaneous  pain  as  well 
as  in  tenderness  to  pressure  ulcerative  conditions 
in  the  stomach  should  always  be  thought  of  first, 
particularly  as  occurring  in  the  middle  region  of  the 
organ,  although  gastric  crises  sometimes,  even  if 
rarely,  are  distinctly  left-sided.  Furthermore,  intes- 
tinal carcinoma,  particularly  of  the  descending  colon 
(radiating  to  the  anus) ,  should  be  thought  of.  When 
there  is  a  tendency  to  flatulence  pain  in  this  region 
is  also  not  uncommon.  Lesions  of  the  pancreas 
(cysts),  affections  of  the  spleen,  and  left-sided  pleu- 
risy, if  the  pain  is  caused  simply  by  pressure,  must 
also  be  considered. 

V.  THE  ABDOMEN  BELOW  THE  UMBILICUS. 

In  order  to  avoid  error,  it  should  always  be  taken 
into  account  that  in  cases  of  enteroptosis  organs 
situated  in  the  upper  part  of  the  abdomen,  such  as 
the  kidney,  stomach,  or  gall-bladder  with  a  corset 
liver,  may  give  rise  to  pain  in  the  lower  abdomen. 
On  the  other  hand,  viscera  originally  situated  in  the 
pelvis  may  in  some  conditions  develop  upwards 
(urinary  bladder,  ovarian  cysts,  extrauterme  preg- 
nancy, etc.).  In  cases  of  bilateral  tenderness  tend- 
ing toward  the  pelvis  ovarian  conditions  and  para- 
metritic  affections  should  be  thought  of  in  women; 
also  conditions  in  the  colon  and  about  the  neighbor- 
ing hernial  openings.  Pain  on  the  left  side  suggests 
the  various  affections  of  the  sigmoid  flexure,  includ- 
ing carcinoma,  dysentery,  membranous  enteritis, 
volvulus,  foreign  bodies  introduced  through  the  anus, 


TOPOGRAPHY  57 

etc.  If  on  the  right  side,  attention  is  directed  to 
lesions  in  the  neighborhood  of  the  caecum  and  the 
appendix,  including  tuberculous  glands  or  ulcera- 
tions,  intestinal  perforation  in  typhoid  fever,  disten- 
tion  of  the  caecum  in  atony  of  the  colon,  etc. 

VI.  THE  LUMBAR  REGION  (SYMMETRICAL). 
Symmetrical  lumbar  pain  is  but  little  adapted  to 
furnish  decisive  diagnostic  information.  After  ex- 
cluding lesions  of  the  musculature  or  fascia,  such  as 
lumbago  and  diseases  of  the  spine,  like  spondylitis, 
osteomylacia,  etc.,  there  is  a  wide  range  of  possibili- 
ties in  which  nearly  all  the  abdominal  organs  com- 
pete, including  particularly  the  female  generative 
system.  The  demonstration  of  alimentary  modifica- 
tion of  the  backache  is  of  importance  since  it  occurs 
in  ulcerative  processes  of  the  stomach  or  large  intes- 
tine. In  these  as  well  as  in  disorders  of  the  colon, 
for  example  carcinoma,  the  pain  often  appears 
within  even  a  few  minutes  after  the  ingestion  of 
cold  fluids  or  solid  food.  This  phenomenon  is  prob- 
ably to  be  interpreted  as  the  result  of  a  reflex  stimu- 
lation of  intestinal  peristalsis.  Accumulations  of 
gas  above  stenoses  appear  to  be  particularly  prone 
to  induce  backache.  Very  deep-seated  carcinomas 
frequently  lead  to  pain  in  the  neighborhood  of  the 
sacrum,  and  the  same  may  be  said  of  haemorrhoidal 
conditions.  Backache  occurring  during  pregnancy 
and  which  is  particularly  severe  on  walking  is  of 
great  practical  significance,  as  it  is  a  symptom  of 
osteomalacia.  A  dependence  on  motion,  particularly 


58  PAIN 

stooping,  is  also  often  present  in  backache  not  orig- 
inating in  the  apparatus  of  motion  itself,  as  in 
hepatic,  splenic,  and  renal  processes,  new  growths 
of  the  colon,  etc. 

The  dorsal  position  is  particularly  likely  to  be 
painful  in  cases  of  retroperitoneal  tumor  formation 
through  enlarged  glands,  aneurysm,  pancreatic  cysts, 
etc.,  and  it  seems  reasonable  to  explain  this  on  the 
ground  of  the  increase  in  compression  accompanying 
this  position.  Prolonged  sitting  sometimes  has  the 
same  effect  when  there  is  swelling  of  abdominal 
organs.  A  rather  rare  condition  that  I  have  ob- 
served is  backache  occurring  in  chronic  lead  poison- 
ing. This  is  sometimes  accompanied  by  radiation 
into  both  thighs  and  is  followed  by  colicky  pain  in 
the  neighborhood  of  the  umbilicus. 

VII.  THE  LUMBAR  REGION  (UNILATERAL) 
AND  THE  FLANKS. 

The  presence  of  spontaneous  pain  or  tenderness 
in  the  right  or  left  lumbar  region  or  in  the  flank  has 
much  greater  diagnostic  value  and  restricts  the  pos- 
sibilities much  more  than  backache  that  is  symmetri- 
cal. Frequently  there  is  no  spontaneous  pain,  but 
it  is  necessary  to  test  for  tenderness  by  pressure,  or 
preferably  by  light  blows  with  the  ulnar  side  of  the 
clenched  fist.  Under  these  conditions  painful  renal 
affections  must  always  be  thought  of,  particularly  if 
the  corresponding  flank  is  also  tender.  Further- 
more, on  the  right  side:  Appendicitis  with  retro- 
csBcal  abscess,  hepatalgia,  and  especially  choleli- 


TOPOGRAPHY  59 

tliiasis.  On  the  left  side :  Gastric  ulcer,  perisplenitis, 
and  pancreatic  lesions. 

ATYPICAL    ABDOMINAL    PAINS. 

"While  the  limits  comprised  under  such  a  heading 
as  this  are  necessarily  arbitrary,  its  introduction  is 
justifiable  from  the  practical  standpoint.  For  vari- 
ous reasons  abdominal  pains  not  rarely  offer  unusual 
difficulties  in  diagnosis.  Frequently  it  does  not  suf- 
fice simply  to  observe  and  to  correlate  the-  observa- 
tions to  form  diagnostic  conclusions,  but  it  is 
necessary  to  go  further  and  consider  even  the  rarer 
possibilities.  The  processes  that  most  often  lead 
to  diagnostic  errors  may  perhaps  be  classified  in  the 
following  way : 

1.  Atypical  Attacks  of  Colic  and  Thoracic  Proc- 
esses.— The  source  of  the  pain  is  found  in  a  more 
or  less  characteristic  and  anatomically  sharply  cir- 
cumscribed organic  lesion,  but  the  attacks  of  pain 
are  rudimentary  or  there  is  an  absence  of  localizing 
symptoms  pointing  to  the  organ  in  question.  It  is 
well  known,  for  example,  that  appendicular  disease 
or  lesions  of  the  gall-bladder  frequently  manifest 
themselves  by  pain  in  the  middle  of  the  epigastrium, 
and  that  biliary  and  ureteral  colic  and  the  pain  of 
pancreatic  disease  may  appear  in  paroxysms  embrac- 
ing a  wide  area.  Wrong  diagnoses  are  to  be  avoided 
only  by  the  most  careful  search  for  a  point  of  maxi- 
mum tenderness,  such  as  the  testicle,  gall-bladder, 
etc.,  and  possible  attendant  symptoms  such  as 
dysuria,  glycosuria,  urobilinuria,  etc.  In  this  con- 


60  PAIN 

nection  those  cases  should  also  be  considered  in 
which  the  source  of  the  abdominal  pain  is  found  out- 
side of  the  abdomen,  like  the  epigastric  pain  of 
chronic  thoracic  aortitis  or  disease  of  the  coronary 
arteries  and  the  tenderness  under  the  costal  arch 
and  in  the  flank  in  cases  of  pleuropneumonic  disease 
of  the  same  side,  etc. 

2.  Cystic  New  Growths  and  Foreign  Bodies  in  the 
Intestine. — Under  this  heading  cyst  formations,  such 
as  those  of  the"  mesentery,  pancreas,  and  ovaries, 
must  be  considered.  As  will  be  pointed  out  in  de- 
scribing pancreatic  pain  the  sensations  attending 
these  are  not  susceptible  of  uniform  interpretation. 
For  example,  mesenteric  cysts  may  on  occasion  give 
rise  to  pain  through  the  obstruction  caused  to  the 
passage  of  gastric  and  intestinal  contents  (direct 
stenosis,  volvulus?),  or  they  may  give  rise  to  second- 
ary neuralgia  (solar  plexus).  The  latter  possibility 
enters  particularly  into  the  question  of  pancreatic 
cysts.  The  obstruction  of  venous  trunks  through  the 
torsion  of  the  pedicle  may  lead  to  a  rapid  increase 
in  pressure  in  the  interior  of  the  cysts  and  therefore 
give  rise  to  pain  through  the  augmented  tension  of 
the  cyst  wall. 

Pathological  processes  in  the  abdominal  lymph 
glands,  both  mesenteric  and  retroperitoneal,  must 
be  thought  of  in  cases  of  obscure  spontaneous  attacks 
of  pain  as  well  as  when  tenderness  to  pressure  exists 
(typhoid,  tuberculosis,  neoplastic  mesenteric  glands, 
etc.).  Swollen  glands,  for  example  in  leukaemia,  are 
particularly  likely  through  compression  of  neighbor- 


TOPOGRAPHY  61 

ing  nerve  centers,  such  as  the  solar  plexus,  to  cause 
neuralgias  of  the  severest  type  and  resembling 
attacks  of  colic.  In  this  group  may  be  included  also 
the  pain  accompanying  the  course*  or  termination  of 
a  tubal  pregnancy  (v.  the  differential  diagnosis  of 
appendicitis). 

3.  Visceral  Neuralgias  and  Disorders  of  Circula- 
tion.— The  cause  of  the  pain  lies  not  in  the  organ 
itself,  but  in  its  nerve  supply  or  in  its  vascular 
system.  Experience  shows  that  cases  of  this  sort 
are  particularly  liable  to  misinterpretation  because 
through  the  law  of  probabilities  lesions  of  the  organs 
themselves  are  more  likely  to  be  thought  of. 

The  neuralgiform  attacks  sometimes  occurring 
in  spinal  diseases,  particularly  in  tabes,  cerebro- 
spinal  syphilis,  etc.,  and  manifesting  themselves  in 
certain  organs,  such  as  the  stomach,  intestine,  blad- 
der, etc.,  as  well  as  independent  processes  in  the 
abdominal  sympathetic  and  its  ramifications  will  be 
taken  up  partly  in  describing  the  various  organic 
pains  and  partly  in  the  discussion  of  the  visceral 
neuralgias.  In  order  to  avoid  repetition,  reference 
is  made  to  the  chapters  in  question.  On  the  other 
hand,  in  the  chapter  on  the  vascular  system  we  shall 
discuss  the  manner  in  which  anatomical  changes  in 
vessels,  like  dilatation,  constriction,  occlusion,  embol- 
ism, and  thrombosis,  may  occasion  pain  in  the  corre- 
sponding organs,  and  reference  will  be  made  to  the 
importance  of  functional  disorders  like  vascular 
spasm.  It  is  therefore  to  be  recommended  always 
to  keep  this  possibility  in  mind  in  investigating 


62  PAIN 

attacks  of  abdominal  pain  in  which  the  necessary 
underlying  factor  such  as  mitral  stenosis,  or  athe- 
roma  with  cardiac  insufficiency  is  present.  It  is  well 
to  remember,  however,  that  these  are  more  or  less 
rare  and  that,  on  the  other  hand,  circulatory  disor- 
ders may  give  rise  to  abdominal  pain  in  other,  even 
though  indirect,  ways.  For  example,  patients  with 
portal  obstruction  are  prone  to  meteorism  and  may 
suffer  from  extremely  severe  pain  from  flatulent 
colic,  or  there  may  be  a  secondary  nephrolithiasis 
due  to  sedimentation  of  urine  in  the  renal  pelvis  of 
a  congested  kidney,  or  complications  like  gastric 
ulcer  or  cholelithiasis  whose  development  appears  at 
times  to  be  favored  through  the  congestion. 

4.  Acute  Intestinal  Stenoses,  Hernias,  etc. — In- 
testinal affections  from  the  borderland  of  surgery 
and  internal  medicine.  Here  we  should  first  con- 
sider the  pain  often  suddenly  arising  under  severe 
general  manifestations,  spontaneously  or  after  ab- 
dominal straining,  and  accompanying  acute  interfer- 
ence with  the  passage  of  intestinal  contents,  whether 
produced  by  external  or  internal  incarceration, 
strangulation,  volvulus,  or  intussusception.  Where 
evidence  is  obtained  pointing  in  this  direction,  such 
as  increased  peristalsis  with  severe  general  symp- 
toms, the  subjective  sensation  of  impeded  intestinal 
activity,  acute  meteorism,  etc.,  the  most  careful  study 
of  the  nature  of  the  pain  is  to  be  recommended. 
While  the  diffuse  colic  attending  these  conditions  is 
not  characteristic,  the  search  after  definite  local 
pain  phenomena  may  be  of  decisive  value.  It  is 


TOPOGRAPHY  63 

above  all  necessary  to  determine  exactly  the  region 
in  which  the  pain  began,  as  this  may  at  least  permit 
conjecture  in  regard  to  the  site  of  the  lesion.  Just 
as  in  chronic  intestinal  stenosis  the  location  of  the 
pain  sometimes  corresponds  to  the  situation  of  the 
obstruction,  the  same  thing  may  be  true  in  acute 
cases.  It  is  of  equal  importance  to  test  for  local 
tenderness  to  pressure,  and  in  this  connection  the 
various  hernia!  openings  should  of  course  be  most 
carefully  examined. 

Gall-stones  or  foreign  bodies  impacted  in  the  in- 
testine may  also  occasion  atypical  local  tenderness 
which  is  difficult  to  interpret.  In  considering  hernial 
pain  the  position  of  the  body  must  be  taken  into 
account  as  well  as  the  local  tenderness,  since  it  may 
determine  the  intensity  of  the  trauma  acting  at  the 
moment  on  the  contents  of  the  hernial  canal  or  her- 
nial opening.  For  example,  the  attitude  of  "Atten- 
tion" or  bending  the  trunk  backward  frequently 
gives  rise  to  pain  in  cases  of  the  extremely  small 
and  therefore  easily  overlooked  hernias  of  the  linea 
alba,  while  on  leaning  forward  the  epigastric  pain, 
which  is  frequently  interpreted  as  due  to  ulcer,  is 
relieved.  Forcible  bending  forward  may  of  course 
also  serve  to  bring  on  the  pain.  Abduction  and  for- 
cible rotation  inward  of  the  thigh  usually  increases 
the  pain  of  incarcerated  obturator  hernia. 

This  group  of  easily  misinterpreted  atypical  ab- 
dominal pains  also  includes  the  more  or  less  painful 
sensations  that  accompany  abnormal  fermentative 
processes  in  the  intestinal  canal.  The  neuropathic 


64  PAIN 

constitution,  enteroptosis,  and  the  tobacco  habit  not 
rarely  furnish  the  underlying  groundwork  of  this 
condition.  The  pain  often  involves  the  flexures  of 
the  colon,  is  frequently  characterized  by  great  sever- 
ity and  a  colicky  nature,  and  may  also  be  accom- 
panied by  local  tenderness.  The  examination  of  the 
stools  is  of  great  importance  and  often  reveals  a 
strongly  acid  reaction  and  an  abnormal  flora  with 
the  presence  of  leptothrix-like  rod  forms  which  give 
the  starch  reaction.  The  pain  frequently  subsides 
rapidly  immediately  after  the  discharge  of  flatus  or 
feces. 


CHAPTER  IV. 

QUALITY  AND  TIME  OF  OCCURRENCE. 

COLICKY  PAINS. — The  classification  of  pains  from 
the  standpoint  of  their  quality,  as  a  rule,  has  but 
little  practical  diagnostic  value.  One  group  stands 
out  distinctly,  however,  and  that  is  the  one  compris- 
ing the  pain  of  colic.  This  is  characterized  by  a 
gradual  onset  and  subsidence,  that  is,  a  wave-like 
curve  of  intensity  with  summits  and  valleys,  and  by 
the  sensation  of  spasmodic  contraction.  The  first 
peculiarity  is  also  manifested  by  the  pain  of  neural- 
gia, and  therefore  in  abdominal  cases  the  recognition 
of  the  nature  of  the  symptom  may  be  attended  by 
considerable  difficulty.  In  such  instances  the  pres- 
ence of  the  spasmodic  element,  as  well  as  possible 
accompanying  manifestations  such  as  active  peri- 
stalsis or  borborygmi,  may  give  the  necessary  clue. 

Pathogenesis  of  the  Pain  of  Colic. — How  does  the 
pain  of  colic  originate!  It  occurs  in  regions  where 
there  are  muscular,  hollow  organs  and  is  linked  with 
this  anatomical  structure.  In  regard  to  the  general 
pathogenesis  of  colic,  from  the  purely  clinical  stand- 
point I  agree  with  those  who  explain  the  phenom- 
enon by  supposing  that  along  the  course  of  a  muscu- 
lar tube  a  band  of  spasmodic  contraction  approaches 
another  fixed  contracted  ring,  driving  before  it  the 
contents  of  the  organ.  As  a  result  of  this  there  must 

5  66 


66  PAIN 

beoverdistentionof  the  constantly  shortening  portion 
lying  between  the  two  rings,  and  I  regard  this  pain 
of  distention  as  being  the  chief  factor  in  the  mechan- 
ism of  the  condition.  It  is  a  fact  that  the  paroxys- 
mal attacks  of  pain  sometimes  occurring  in  lesions  of 
the  renal  parenchyma  (nephritis,  tumor,  etc.)  as  the 
result  of  acute  congestion,  haemorrhage,  etc.,  in  their 
qualitative  shading  are  hardly  to  be  distinguished 
from  the  pains  of  colic.  Here  the  distention  of  the 
capsule  is  probably  the  only  active  factor.  If  the 
stationary  ring  of  contraction  relaxes,  the  formerly 
distended  portion  collapses,  the  tension  of  the  wall 
subsides  and  the  contents  move  on.  This  may  be 
directly  observed  in  cases  of  gastro-intestinal  ste- 
nosis. The  advance  of  the  contents  is  rendered  evi- 
dent by  loud  borborygmi,  and  with  their  onset  the 
pain  usually  subsides.  Is  the  stationary  contraction 
ring  itself  a  source  of  pain  I  It  is  a  fact  that  cases 
may  be  observed  in  which  a  spastic  tumor  at  the 
pylorus  of  an  entirely  empty  stomach  suddenly 
appears  under  the  palpating  fingers,  while  at  the 
same  time  severe  pain  is  felt  by  the  patient.  As  the 
tumor  vanishes  the  pain  also  ceases.  It  seems  out 
of  the  question  in  such  a  case  to  assume  the  existence 
of  distention  of  the  walls  in  view  of  the  empty  con- 
dition of  the  stomach,  and  observations  of  this  sort 
appear  to  me  to  indicate  that  local  spasm  of  the 
nature  of  the  ordinary  sural  cramp  is  also  capable 
of  evoking  the  pain.  In  regard  to  the  separate 
forms  of  colic,  the  differential  diagnosis,  etc.,  refer- 
ence may  be  made  to  the  discussion  of  the  individual 


OCCURRENCE  67 

organic  pains  as  well  as  to  the  section  on  atypical 
abdominal  pains. 

For  the  purposes  of  rapid  orientation  in  doubtful 
cases  of  colic  it  should  be  remembered  that  unilateral 
tenderness  of  the  testicle  to  pressure,  disorders  in 
the  evacuation  of  urine  and  in  its  nature,  and  pain  on 
pressure  in  the  renal  region  are  found  in  ureteral 
colic.  Elevation  of  temperature,  ileocsecal  pain,  and 
leucocytosis  accompany  appendicitis.  The  exami- 
nation may  also  require  a  search  for  tenderness  and 
enlargement  of  the  liver  and  gall-bladder,  mesenteric 
or  ovarian  cysts,  extrauterine  pregnancy,  tenderness 
about  the  hernial  openings,  gastro-intestinal  peri- 
stalsis, sarcinae  in  the  stools  and  in  the  gastric  con- 
tents which  occur  in  stenosis  of  the  pylorus,  lead  line 
on  the  gums,  abnormalities  of  the  pupillary  and 
patellar  reflexes,  glycosuria  and  the  absence  of  indi- 
can  with  peritoneal  symptoms  indicating  pancreatic 
disease,  glandular  masses  in  the  neighborhood  of  the 
solar  plexus,  menstrual  irregularities,  and  cardiac 
and  aortic  lesions  pointing  to  angina  pectoris  with 
epigastric  localization. 

The  time  of  occurrence  of  the  pain  has  differen- 
tial value  only  if  there  is  regularity  in  this,  or  if 
there  is  a  relationship  to  the  ingestion  of  food  or  to 
organic  function.  In  this  connection  reference  may 
be  made  to  what  has  been  said  above. 

NOCTUKNAL  PAINS. — A  special  group  is  formed 
by  attacks  of  pain  characterized  by  more  or  less  ex- 
clusively nocturnal  onset.  An  undeniable  relation- 
ship in  this  regard  is  manifested  by:  (1)  The  pain 


68  PAIN 

of  colic  in  general.  As  a  physiological  example 
labor  pains  deserve  the  first  place.  With  the  inactiv- 
ity of  striped  muscle  there  seems  to  be  associated  an 
increased  activity  of  the  smooth  muscle  fibres,  and 
it  may  be  said  that  at  night  smooth  muscle  is  in  the 
ascendant.  Colicky  seizures  of  the  most  varied  sorts 
show  a  pronounced  tendency  to  manifest  themselves 
during  the  midnight  hours.  (2)  Pains  due  to  a 
dyscrasia.  In  this  category  may  be  included  the 
uraemic  headaches,  urasmic  cramps  of  the  calf 
muscles,  and  gouty  seizures.  It  seems  to  me  natural 
to  assume  that  as  a  result  of  the  diminution  in 
metabolic  function  through  the  absence  of  muscular 
work  and  its  attendant  respiratory  and  cutaneous 
activity,  when  a  dyscrasia  exists  the  toxaBmic  curve 
ascends  at  night  and  leads  to  nocturnal  attacks  of 
pain.  The  connection  between  syphilis  and  noctur- 
nal pain  may  accordingly  be  regarded  only  as  a  par- 
ticular example  of  a  connection  actually  having  a 
much  deeper  foundation. 


CHAPTER  V. 

THE  NERVOUS  SYSTEM. 
HEADACHE. 

THIS  designation,  although  it  really  connotes  only 
a  topographical  characteristic  of  the  pain,  is  usually 
employed  when  an  organic  pain  is  in  question,  that 
is,  cerebral  pain.  In  order  to  justify  the  latter 
assumption,  it  is  necessary  to  regard  the  brain,  to- 
gether with  its  enveloping  membranes,  as  an  entity, 
a  principle  that,  by  the  way,  will  be  found  per- 
fectly natural  in  the  description  of  hepatic,  splenic 
or  renal  pains,  etc.  Paradoxical  as  it  may  seem  at 
the  first  blush  to  draw  parallels  of  any  sort  between 
organs  that  are  so  different  in  function  and  struc- 
ture, it  cannot  be  denied  that  the  general  basis  of  the 
phenomena  of  pain  in  the  organs  just  mentioned 
possesses  certain  characteristics  in  common.  Varia- 
tions in  the  volume  of  the  organs  with  the  attending 
tension  of  the  capsule,  and  more  or  less  independent 
inflammatory  processes  of  their  enveloping  mem- 
branes, are  important  factors  in  the  general  pathol- 
ogy of  pain  involving  the  organs  in  question.  For 
example,  in  proportion  as  the  volume  of  a  congested 
liver  diminishes  under  the  action  of  digitalis  its  ten- 
derness to  pressure  decreases,  to  reappear  again 
suddenly  at  a  time  when  auscultation  demonstrates 
the  onset  of  a  perihepatitis.  In  this  case  the  condi- 

69 


70  PAIN 

tions  are  plainly  evident,  for  the  organ  is  accessible 
to  direct  physical  examination.  It  is  different  in 
cases  of  cephalalgia,  for  although  the  ophthalmo- 
scope may  give  valuable  information,  for  the  most 
part  we  are  confronted  by  the  rigid  bony  cranium 
which  sets  at  naught  our  efforts  in  the  way  of  physi- 
cal examination.  We  are  therefore  forced  to  form 
an  opinion  concerning  the  general  mechanism  of  pain 
from  case  to  case,  taking  into  consideration  the  modi- 
fying factors  and  the  accompanying  manifestations. 
Under  these  conditions  it  is  hardly  possible  to  avoid 
reasoning  by  analogy. 

FUNDAMENTAL  CAUSES  OF  HEADACHE. — The  follow- 
ing factors  of  general  pathology  may  be  grouped 
as  belonging  to  the  fundamental  causes  of  headache : 

I.  Mechanical  factors,  involving  a  rise  in  intra- 
cranial  pressure:  (a)  Chronic  (new  growths,  hydro- 
cephalus).     (b)  Acute.    Under  this  heading  vaso- 
motor   disturbances  must  be  considered,   such  as 
angioneurotic  hydrocephalus  and  also  interference 
with  the  venous   return,   as   in  sinus   thrombosis, 
paroxysms  of  coughing  accompanying  congestion  in 
the  superior  vena  cava  in  consequence  of  mediastinal 
new  growths,  tricuspid  insufficiency,  etc. 

II.  Chemical  factors:  Anaemia,  toxaemia,  inflam- 
mation. 

III.  Eeflex  factors. 

The  meninges,  receiving  their  innervation  from 
the  trigeminal  nerve,  are  to  be  regarded  as  the  com- 
mon point  of  attack  of  all  these. 


THE   NERVOUS   SYSTEM  71 

I.  Headache  Due  to  Chronic  or  Acute  Elevations 
of  Intracranial  Pressure. 

By  way  of  preface,  it  may  be  pointed  out  that 
increased  pressure  in  the  arterial  system  sometimes 
occurs  together  with  intracranial  hypertension,  and 
may  under  certain  conditions  serve  as  a  predisposing 
factor.  On  the  other  hand,  it  is  evident  that  intra- 
cranial tension  may  also  be  increased  in  cases  of 
low  arterial  pressure. 

BRAIN  TUMOR  AND  HYDROCEPHALTJS. — The  ana- 
tomical processes  to  be  considered  in  this  connection 
are  in  the  first  place  tumors,  which  may  increase 
cerebral  pressure  partly  per  se  through  the  increase 
in  the  bulk  of  the  intracranial  contents,  but  which 
may  also  do  this  as  a  consequence  of  their  relation- 
ship to  important  channels  such  as  the  veins  of  Galen 
or  the  aqueduct  of  Sylvius.  The  latter  element  par- 
ticularly serves  to  explain  the  fact  that  of  the  intra- 
cranial processes  leading  to  headache  tumors  of 
the  posterior  fossa  deserve  first  place.  Cerebral 
abscesses,  of  course,  behave  in  the  same  way.  A 
form  of  hypertension  headache  is  caused  in  those 
cases  of  acquired  hydrocephalus  of  adults  in  which 
the  manifestations  of  increased  cerebral  pressure 
arise,  sometimes  in  stormy  fashion  with  the  symp- 
toms of  an  infectious  disease  (serous  meningitis),  in 
other  cases  in  a  more  or  less  insidious  manner,  or 
at  least  without  evidences  of  acute  infection.  The 
etiology  of  these  cases  of  hydrocephalus  running  a 
course  like  that  of  brain  tumor  is  far  from  clear, 


72  PAIN 

and  the  assumption  of  the  existence  of  chronic  menin- 
gitic  processes  is  usually  a  mere  hypothesis.  Intes- 
tinal processes  such  as  constipation  with  acetonuria, 
as  well  as  anaemic  blood  changes  like  chlorosis,  seem 
to  have  some  causative  influence.  The  headache 
arising  under  these  conditions  resembles,  particu- 
larly in  the  acute  cases,  the  headache  of  acute  menin- 
gitis, and  also,  it  is  true,  the  hypertension  headache 
of  brain  tumors.  The  headache  of  acute  meningitis 
may  also  be  included  in  this  category. 

POSITION  OF  THE  HEAD. — On  careful  observation 
of  such  cases  of  hypertension  headache,  as  I  may 
briefly  call  them,  it  is  undeniable  that  the  position 
and  motion  of  the  head  is  of  considerable  influence 
on  the  pain.  The  patient  often  succeeds  in  reducing 
his  suffering  to  a  minimum  by  bending  the  head  far 
backward  and  burying  it  in  the  pillow.  No  doubt 
this  position  produces  a  certain  diminution  of  ten- 
sion and  may  be  compared  to  the  midposition  as- 
sumed by  inflamed  joints.  On  the  contrary,  bending 
the  head  forward  appears  to  increase  the  pain,  and 
similarly,  rotation  of  the  head  is  often  painful,  the 
sensation  usually  being  experienced  in  the  nape  of 
the  neck  and  sometimes  apparently  on  the  side  oppo- 
site to  that  toward  which  rotation  has  taken  place. 
On  lying  down  the  patients  not  rarely  fix  the  head 
with  the  hand.  Swallowing  sometimes  serves  to 
bring  on  pain.  The  patient  therefore  usually  at- 
tempts to  bring  the  head  into  a  certain  "midposi- 
tion" and  to  maintain  it  passively  in  this  attitude 
without  innervation  of  the  neck  muscles.  Another 


THE  NERVOUS  SYSTEM  73 

set  of  painful  stimuli  have  in  common  the  fact  that 
through  increased  heart  action  the  blood  supply  to 
the  brain  is  increased  but  the  venous  return  is  in- 
hibited. Of  this  description  are  various  mechanical 
factors  like  stooping,  lifting  weights,  sitting  up 
rapidly  or  lying  down  quickly,  the  horizontal  posi- 
tion, hard  straining  at  stool,  etc.  Extreme  heat  may 
act  in  a  similar  way,  and  is  usually  not  well  borne. 
Furthermore,  various  chemical  stimuli  of  a  dietetic 
nature  may  be  mentioned,  such  as  the  use  of  alcohol, 
tobacco,  coffee,  tea,  etc. 

HEADACHE  AND  CONSTIPATION. — Finally,  I  should 
like-  to  call  attention  to  the  frequently  very  close  re- 
lationship between  hypertension  headache  and  con- 
stipation. Practically  this  is  of  the  greatest  impor- 
tance, but  theoretically  it  is  no  less  interesting. 
When  hypertension  headache  appears  in  conjunction 
with  constipation  of  long  duration,  for  example,  in 
chlorotic  persons,  together  with  other  symptoms  of 
intestinal  intoxication  like  urticaria,  acetonuria,  etc., 
a  causative  connection  immediately  suggests  itself, 
and  as  a  matter  of  fact  calomel  is  a  sovereign 
remedy  in  these  cases.  I  can  also  recall  cases  of 
undoubted  hypertension  headache  in  cerebral  tumor 
in  which  the  administration  of  a  laxative  gave 
prompt  relief  and  far  surpassed  the  effect  of  the 
antineuralgics  prescribed.  The  connection  between 
constipation  and  headache  is  undeniable,  but  the  ex- 
planation of  this  is  pure  theory.  The  widely  sup- 
ported toxin  theory  seems  to  me  to  be  not  very  satis- 
factory, or  at  least  not  of  itself  all  sufficient,  in  view 


74  PAIN 

of  the  extreme  suddenness  with  which  the  pain  often 
ceases  on  evacuation  of  the  bowels.  In  this  connec- 
tion the  role  played  by  intestinal  peristalsis  as  an 
accessory  to  the  portal  circulation  might  be  thought 
of  as  well  as  the  interference  with  circulation  in 
the  domain  of  the  superior  vena  cava  that  results 
through  constipation  and  gas  accumulation  in  the 
abdomen,  owing  to  the  pushing  upward  of  the 
diaphragm. 

TOPOGRAPHY  AND  ACCOMPANYING  MANIFESTATIONS. 
A  topographical  peculiarity  of  hypertension  head- 
ache appears  to  me  to  lie  in  its  preference  for  the 
nape  of  the  neck,  as  well  as  in  its  tendency  to  radiate 
along  the  spinal  column,  particularly  in  the  region 
between  the  shoulder  blades.  The  patients  fre- 
quently complain  of  feeling  "as  if  the  head  were 
being  split  open,"  "as  if  the  head  would  burst 
open, ' '  sensations  that  may  well  be  in  harmony  with 
the  underlying  condition.  Changes  in  the  fundus 
of  the  eye  are  particularly  prominent  among  the 
accompanying  manifestations.  They  may  be  partly 
of  purely  mechanical  nature,  such  as  dilatation  of 
the  veins,  or  haemorrhages;  partly  inflammatory  in 
origin.  In  these  cases  there  may  be  lymphatic  con- 
gestion with  an  accumulation  of  the  products  of 
metabolism,  and  it  may  readily  be  assumed  that  not 
only  in  the  optic  nerve  but  also  in  the  trigeminal  or 
occipital  nerves  similar  alterations  may  develop  with 
secondary  neuralgia.  Pressure  points  may  often  be 
demonstrated  over  the  distribution  of  the  occipital 
and  trigeminal  nerves.  Hiccough,  vomiting,  and  ab- 


THE   NERVOUS   SYSTEM  75 

normalities  in  pulse  and  respiration  may  be  re- 
garded as  vagus  symptoms.  Not  rarely  symptoms 
due  to  irritation  of  the  optic  and  acoustic  nerves 
are  observed,  such  as  spots  dancing  before  the  eyes 
or  buzzing  in  the  ears,  as  well  as  attacks  of  vertigo. 
While  the  explanation  on  mechanical  grounds  of 
the  headache  accompanying  intracranial  processes 
that  encroach  on  the  available  space  is  satisfactory, 
the  headaches  caused  in  other  ways  are  difficult  to 
understand.  The  thought  suggests  itself  that  the 
same  mechanical  factor  of  elevation  in  intracranial 
pressure  that  exists  permanently  and  to  an  extreme 
degree  in  the  processes  described  above  may  also 
occur  intermittently  and,  so  to  speak,  in  rudimentary 
form.  Here  consideration  from  case  to  case  of  the 
mode  of  onset  and  accompanying  symptoms  may 
serve  to  give  the  clue.  For  example,  headache  such 
as  occurs  in  persons  with  neurasthenic,  irritable 
weakness  of  the  vasomotor  system  after  psychical 
excitement,  mental  exertion,  straining  the  eyes 
through  reading,  etc.,  may  be  explained  in  this  way. 
These  are  influences  that,  according  to  general 
physiological  conceptions,  are  associated  with  in- 
creased blood  supply  to  the  organs  in  question,  and 
temporary  intracranial  elevations  of  pressure  might 
easily  be  produced,  particularly  if  there  is  a  condi- 
tion of  vasomotor  ataxia  induced  through  nicotinism. 
The  elevation  of  blood  pressure  which  is  so  often 
seen  in  neurasthenics  may  serve  as  a  favoring  factor, 
and  this  condition  always  deserves  consideration  in 


76  PAIN 

the  diagnosis  and  treatment  of  headache.  In  gen- 
eral the  neurasthenic  headache  is  characterized  by 
the  readiness  with  which  it  is  influenced  by  the  re- 
moval of  the  exciting  cause  (mental  exertion,  sexual 
habits,  etc.). 

II.  Headache  Caused  by  Chemical  Poisons. 

UREMIA. — Albuminuric  headache  or  the  cephal- 
algia  caused  by  renal  insufficiency  may  be  taken  as  a 
paradigm  of  this  type,  although  here  in  addition  to 
the  toxaemic  element  no  doubt  mechanical  factors, 
such  as  cerebral  redema  or  hydrocephalus,  together 
with  arterial  hypertension,  frequently  play  a  not  un- 
important role  in  the  pain  production.  The  relief 
to  the  pain  that  frequently  follows  epistaxis  or 
blood  letting  at  the  mastoid  process  may  be  ex- 
plained on  this  basis.  As  with  the  headache  of 
hypertension,  the  seat  of  the  uraemic  headache  is  not 
rarely  the  occipital  region  but  in  general  it  may  be 
said  that  there  are  no  entirely  characteristic  fea- 
tures, so  that  in  every  case  of  obstinate  cephalalgia 
the  examination  of  the  urine  for  serum  albumin  is 
urgently  demanded.  The  prompt  effect  frequently 
following  large  doses  of  cerium  oxalate  (about 
0.5  g.)  is  an  interesting  fact.  It  is  difficult  to  deter- 
mine to  what  extent  the  headache  occurring  in  cases 
of  angiosclerosis  without  albuminuria  depends  on 
arterio sclerotic  renal  insufficiency.  Here  again  the 
high  blood  pressure  may  come  into  play,  as  appears 
to  me  to  be  shown  by  the  relief  not  infrequently 
afforded  by  an  incidental  nose-bleed,  so  that  the 


THE  NERVOUS  SYSTEM  77 

advisability  of  producing  this  artificially  may  even 
suggest  itself. 

LEAD  POISONING  AND  GOUT. — The  basis  of  the 
headache  in  chronic  lead  and  metal  poisoning  in 
general  is  probably  not  constant,  and  the  same  thing 
is  true  of  the  uric  acid  diathesis  and  the  peculiar 
type  of  headache  well  known  to  the  laity  as  migraine. 
It  is  true  nevertheless  that  Trousseau's  classical 
dictum,  "migraine  and  gout  are  sisters,"  deserves 
full  consideration. 

INFECTIOUS  PKOCESSES. — The  relations  between 
infectious  processes  such  as  syphilis,  malaria,  tuber- 
culosis, influenza,  etc.,  and  their  associated  head- 
aches, are  no  less  uncertain.  In  part,  there  may  be 
direct  toxic  action  on  the  pain-conducting  trigeminal 
tract;  in  part,  transitory  elevations  of  intracranial 
pressure  incited  through  inflammatory  hyperasmia 
of  the  meninges  and  the  intracerebral  blood  vessels. 
This  holds  also  for  cases  of  suppurative  or  tubercu- 
lous meningitis. 

ANEMIA. — It  is  undeniable  that  patients  with 
blood  changes,  such  as  chlorosis  or  pernicious 
anaemia,  not  rarely  suffer  from  headache,  and  it  is 
equally  true  that  headache  is  often  entirely  absent 
in  cases  of  pernicious  anaemia  of  the  most  severe 
sort.  It  is  hardly  wise  therefore  to  speak  off-hand 
of  an  anaemic  headache.  When  headache  is  espe- 
cially intense  in  anaemic  patients,  the  idea  of  intra- 
cranial rise  in  pressure  through  hydremic  hydro- 
cephalus  suggests  itself.  In  such  cases  elevating 
the  head  is  frequently  of  benefit,  and  the  patients 


78  PAIN 

often  behave  in  a  manner  similar  to  that  discussed 
under  the  heading  of  hypertension  headache.  Just 
as  hydremia  appears  to  predispose  to  fluid  exudates 
in  general,  it  seems  sometimes  to  give  rise  to  transu- 
dation  into  the  ventricles  of  the  brain.  This  is  not 
intended  to  deny,  however,  that  anaemic  blood 
changes  may  not  cause  headache  without  an  inter- 
mediate condition  of  hydrocephalus.  These  are 
then  susceptible  to  the  same  therapeutic  measures 
as  the  underlying  condition  and  are  relieved  by  a 
more  abundant  blood  supply,  such  as  is  caused  by 
lowering  the  head. 

III.  Headache  of  Reflex  Nature. 

Here  irritative  stimuli  are  concerned — particu- 
larly in  the  distribution  of  the  trigeminal  nerve — 
which  under  some  circumstances  may  find  an  echo, 
as  it  were,  through  radiation  in  the  meningeal  dis- 
tribution of  this  nerve.  Even  in  cases  of  restricted 
localization  the  differentiation  may  be  difficult  be- 
tween neuralgia  and  cephalalgia  in  the  sense  of  cere- 
bral pain.  At  any  rate,  in  making  the  differential 
diagnosis  of  headache,  it  is  advisable  not  to  leave 
out  of  consideration  any  existing  manifestations  in 
the  distribution  of  the  trigeminal  nerve. 

THE  EYE,  NOSE,  AND  EAR. — This  is  especially 
true  of  the  eye;  the  combination  of  headache  and 
visual  disturbances  should  always  lead  to  the  most 
careful  examination  of  the  eye,  including  investiga- 
tion of  the  tension  of  the  eyeball,  the  visual  field, 
and  examination  for  excavation  of  the  optic  disc. 


THE  NERVOUS   SYSTEM  79 

Furthermore,  there  is  no  doubt  that  other  disturb- 
ances such  as  weakness  in  convergence,  hyperme- 
tropia  or  presbyopia,  astigmatism,  etc.,  may  furnish 
the  starting  point  of  headache,  especially  in  cases  in 
which  a  general  predisposition  to  headache  is 
already  supplied  by  other  factors  such  as  the 
neuropathic  constitution,  disorders  of  nutrition, 
etc.  Overzealous  treatment  by  specialists  must 
therefore  be  deprecated  and  the  general  pre- 
disposing condition  should  receive  full  therapeu- 
tic attention.  This  is  equally  true  in  regard 
to  the  relations  between  headache  and  inflam- 
matory and  suppurative  disease  or  swellings  in  the 
nasal  passages  and  their  accessory  cavities  (frontal 
headache  in  iodide  coryza,  etc.).  Particularly  con- 
vincing are  those  cases  in  which  months  of  anti- 
neuralgic  treatment  of  obstinate  frontal  headache 
are  suddenly  permanently  terminated  by  the  dis- 
charge of  a  quantity  of  pus  through  the  nose.  Proc- 
esses in  the  frontal  and  sphenoid  sinuses  are  of 
particular  significance  in  this  connection.  That  the 
ear  should  require  full  consideration  among  the 
organs  of  special  sense  is  evident  through  the  pos- 
sibility of  otogenous  cerebral  abscesses,  sinus 
thrombosis,  etc.  The  examination  of  the  mastoid 
process  for  tenderness  should  never  be  omitted. 

STOMACH  AND  INTESTINE. — Any  existing  gastro- 
intestinal disorders  (parasites,  constipation,  dys- 
pepsia, latent  cholelithiasis)  must  also  be  taken  into 
account.  Just  as  cerebral  processes  like  brain 
tumors,  meningitis,  or  migraine  frequently  evoke 


80  PAIN 

vomiting,  constipation,  or  other  secondary  gastro- 
intestinal disturbances,  a  similar  influence  seems  to 
be  possible  in  the  opposite  direction  also.  Stag- 
nation of  fecal  masses  deserves  consideration,  as 
has  already  been  indicated.  Even  though  the  head- 
ache may  seldom  be  caused  by  constipation  alone, 
this  often  affords  an  important  contributing  cause, 
the  removal  of  which,  as  for  example  in  cases  of 
brain  tumor,  may  lead  to  an  immediate  and  con- 
siderable improvement  in  the  pain.  In  women, 
affections  of  the  genital  apparatus  also  require 
careful  attention. 

DIFFERENTIAL  DIAGNOSIS. — In  the  differential 
diagnosis  of  headache  it  is  necessary  first  to  deter- 
mine the  primary  causes  of  the  condition  and  to 
determine  its  position  in  one  of  the  three  main 
groups  mentioned  above.  It  is  better  not  to  label 
the  case  at  all  than  to  resort  to  so  inadequate  a  term 
as  "nervous  headache,"  "habitual  headache,"  etc. 

TOPOGRAPHY. — An  exact  inquiry  into  the  details 
of  the  pain  frequently  gives  important  clues  in  re- 
gard to  its  causation.  Localization  of  the  pain  at 
the  back  of  the  head  and  the  nape  of  the  neck  radiat- 
ing downward  along  the  spinal  column  between  the 
shoulder  blades,  would  suggest  particularly  hyper- 
tension headache  or  renal  headache,  if  there  is  no 
disease  of  the  vertebral  column  itself  or  rheumatic 
affection  of  the  neck  muscles  (torticollis).  Involve- 
ment of  the  frontal  region,  on  the  other  hand,  would 
direct  attention  to  functional  disorders  of  the  eye 
or  diseases  of  the  nose  and  nasal  sinuses,  particu- 


THE   NERVOUS  SYSTEM  81 

larly  the  frontal  sinus.  The  depth  at  which  the  pain 
is  said  to  be  situated  is  always  of  importance.  Su- 
perficial headache -points  to  trigeminal  neuralgia  or 
rheumatic  disease  of  the  galea.  A  unilateral  head- 
ache indicates  idiopathic  migraine,  if  an  appropriate 
history  is  obtained  of  hereditary  predisposition, 
onset  in  youth,  and  typical  accompanying  manifesta- 
tions like  vomiting,  scintillating  scotoma,  etc.  If 
hemicrania  begins  later  in  life,  a  secondary  form 
such  as  that  due  to  tumor,  nephritis,  syphilis,  etc., 
is  suggested. 

QUALITY  AND  INTENSITY. — The  quality  and  sever- 
ity of  the  pain  also  deserve  analysis.  In  general 
the  greatest  intensity  is  exhibited  by  hypertension 
headache,  the  attacks  of  migraine,  and  trigeminal 
neuralgia.  The  quality  of  the  pain  of  the  first-men- 
tioned type,  which  is  often  described  as  * '  splitting, ' ' 
harmonizes  well  with  the  underlying  process,  which 
frequently  no  doubt  involves  a  maximum  of  intra- 
cranial  pressure.  The  time  of  onset,  too,  may  give 
a  clue.  Headache  appearing  only  by  day  is  prob- 
ably not  of  syphilitic  o'rigin,  but  nocturnal  increases 
in  intensity  are  also  observed  in  non-luetic  cerebral 
processes,  such  as  brain  tumor  or  uraemia. 

MODIFYING  FACTORS. — Most  suggestive  indica- 
tions are  generally  afforded  by  a  careful  considera- 
tion of  the  conditions  under  which  the  pain  is  modi- 
fied. Headache  primarily  of  psychical  origin  is  the 
most  readily  susceptible  to  psychical  influences. 
The  greater  the  part  played  in  the  etiology  by 
mechanical  factors,  especially  intracranial  hyper- 
6 


82  PAIN 

tension,  the  more  will  purely  mechanical  factors, 
such  as  position  of  the  head  and  body,  movement  of 
the  head,  local  bleeding,  etc.,  have  the  power  to  in- 
fluence the  pain.  In  this  connection  reference  may 
be  made  to  what  was  said  above  regarding  hyperten- 
sion headache.  Palpation  of  the  skull  is  always  to 
be  recommended  in  order  to  discover  any  possible 
pressure  points  corresponding  to  the  emergence  of 
sensory  nerves  (trigeminal  or  occipital),  syphilitic 
periostitis,  or  rheumatic  changes  in  the  calvarium 
or  cranial  aponeurosis.  The  effect  of  refrigeration 
through  draughts,  cold,  etc.,  comes  in  question  par- 
ticularly in  neuralgia  and  rheumatic  headaches  or 
those  of  extracerebral  nature.  Heat  is  frequently 
badly  borne  in  hypertension  headache. 

In  this  way  the  analysis  of  the  pain  itself  will 
frequently  guide  the  examiner  in  one  direction  or 
another,  even  though  the  diagnosis  does  not  at  once 
follow.  The  careful  and  detailed  general  physical 
examination  is  not  to  be  avoided  in  this  way,  but  may 
be  shortened.  Certain  tests  are  always  to  be  recom- 
mended for  the  purpose  of  rapid  orientation : 

1.  Estimation  of  the  blood  pressure  and  of  any 
existing  vascular  changes  (nephritis,  angiosclerosis, 
lead  poisoning). 

2.  Pulse  rate    (bradycardia  in   tumors,   hydro- 
cephalus,  meningitis). 

3.  Examination  of  the  urine  for  serum  albumin 
and  acetone.    In  intestinal  autointoxication  these 
appear  early,  but  in  meningitis  later. 


THE   NERVOUS  SYSTEM  83 

4.  Testing  the  intra-ocular  tension  in  order  not 
to  overlook  a  case  of  glaucoma. 

5.  Ophthalmoscopic  examination  of  the  fundus 
of  the  eye. 

6.  Testing   the   patellar   reflex,   which   may   be 
absent  in  cerebellar  tumors  or  meningitis. 

7.  Testing  the  pupils  (syphilis  and  meningitis). 

Among  the  cranial  nerves  the  facial  and  hypo- 
glossal  ^deserve  most  attention,  as  slight  disorders 
of  either  of  these  do  not  give  rise  to  complaint  and 
are  therefore  easily  overlooked. 

In  taking  the  history,  attention  must  be  paid  to 
such  accompanying  manifestations  as  vomiting, 
which  suggests  hypertension  headache,  migraine,  or 
glaucoma,  and  acute  disturbances  of  vision  indicat- 
ing migraine,  glaucoma,  or  nephritis.  The  matter 
of  preceding  or  still  existing  nasal  or  aural  dis- 
orders should  also  be  investigated.  Lacrimation 
or  secretory  disturbances  of  the  nasal  mucosa  or 
salivary  glands,  accompanying  the  attacks  of  pain, 
arouse  suspicion  of  the  existence  of  trigeminal 
neuralgia. 

NEURALGIAS   INVOLVING   THE   GENERAL 
NERVOUS  SYSTEM. 

Inasmuch  as  every  stimulus  requires  transmis- 
sion by  the  nerve  trunks  in  order  to  be  experienced 
as  a  sensation,  it  at  first  seems  rather  paradoxical 
to  speak  of  "nerve  pains"  as  a  distinct  variety. 
Clinically,  however,  this  term  connotes  the  concep- 
tion that  the  source  of  the  pain  is  not  to  be  found 


84  PAIN 

in  the  parenchyma  of  an  organ,  from  which  it  is 
transmitted  to  the  sensorium  through  the  special 
nerve  trunk  belonging  to  the  organ,  but  rather  that 
it  acts  upon  the  sensory  trunk  itself  in  its  peripheral 
portion.  The  first  task  of  the  diagnostician  is  to 
discover,  as  far  as  possible,  the  seat  and  variety  of 
this  cause.  If  this  attempt  is  not  successful  the 
assumption  is  warranted  that  there  is  present  a 
neuralgia  in  the  more  restricted  sense;  that  is,  a 
nerve  pain  concerning  whose  etiological  basis  bio- 
chemical information  is  not  yet  available  and  histo- 
logical  investigations  will  probably  never  enlighten 
us  fully.  It  is  therefore  necessary  to  keep  in  mind 
that  the  diagnosis  of  neuralgia  in  its  restricted  sense 
is  a  diagnosis  by  exclusion  and  that  up  to  a  certain 
point  it  remains  doubtful.  Repeated  reinvestigation 
in  regard  to  the  etiology  is  accordingly  extremely 
desirable. 

The  point  of  attack  of  the  neuralgia-producing 
factor  is  probably  in  most  cases  to  be  found  in  the 
course  of  the  peripheral  neurone.  Nevertheless  it 
is  desirable  to  remember  that  the  central  conducting 
tracts,  the  medulla,  pons,  optic  thalami,  and  their 
surroundings,  and  probably  also  the  cerebral  cortex, 
as  well  as  the  posterior  portions  of  the  gray  matter 
of  the  cord,  may  be  the  seat  of  the  disease.  In  these 
anatomical  districts  pain  may  be  produced,  not  only 
as  the  result  of  organic,  but  also  from  functional 
disturbances.  The  neuralgias  arising  in  hysteria, 
cerebral  tumors,  tabes,  syringomyelia,  myelitis,  etc., 
are  probably  to  some  extent  to  be  interpreted  as 


THE  NERVOUS  SYSTEM  85 

having  a  central  origin  of  this  nature.  Much  more 
varied  are  the  general  and  special  factors  that  give 
rise  to  neuralgias  in  the  peripheral  nervous  system. 
As  it  seems  advisable  to  pass  these  in  review  in 
every  doubtful  case,  I  wish  to  make  at  least  the 
attempt  to  arrange  them  in  classified  form. 

A.  DIEECT  FACTORS. 

1.  Mechanical. — These  are  principally  pressure 
effects  through  new  growths,  particularly  glandular 
swellings,  aneurysms,  inflammatory  processes  with 
exudation  in  the  neighborhood  of  nerves,  hernias, 
etc. 

2.  Thermic. — This  group  includes  the  complex 
of  stimuli  comprised  under  chilling,  draughts,  etc., 
the  mode  of  action  of  which  is  difficult  to  analyze. 
The  underlying  cause  frequently  lies  much  deeper 
and  the  thermic  stimuli  have  only  an  exciting  effect. 

3.  Chemical  Factors  with  Secondary  Disorders 
of  Nutrition. — Their  point  of  attack  is   certainly 
often  indirect,  involving  the  vascular  system.     Scle- 
rotic   and    spastic    conditions    in    the    domain    of 
the  vasa  nervorum  must  not  be  forgotten  in  this 
connection. 

(a)  Non-infectious    exogenous    toxins:     Proto- 
plasmic poisons  of  the  most  varied  nature  would  be 
included  here,  such  as  arsenic,  lead,  alcohol,  nico- 
tine, mercury,  etc. 

(b)  Toxins  infectious  in  nature:    Syphilis,  ma- 
laria, influenza,  tuberculosis,  gonorrhoea,  etc. 


86  PAIN 

(c)  Dyscrasic  endogenous  toxins:  Gout,  carci- 
noma, diabetes,  nephritis,  anaemia,  adiposis  dolorosa 
of  Dercum. 

Here  may  best  be  included  also  those  local  dis- 
turbances of  metabolism  that  underlie  the  so-called 
occupation  neuralgias  which  result  from  the  exces- 
sive use  of  certain  nerve  tracts.  Furthermore  the 
attacks  of  pain  involving  the  distal  portions  of  the 
extremities  and  accompanied  by  vasomotor  disturb- 
ances, such  as  erythromelalgia,  Raynaud's  disease, 
etc. 

B.  EEFLEX  FACTORS. 

The.  stagnation  of  fecal  masses,  intestinal  para- 
sites, various  visceral  disorders  involving  the  heart, 
gall-bladder,  genital  apparatus,  kidney,  etc.,  may  be 
concerned  in  the  causation  of  neuralgias,  and  it  is 
natural  to  assume  a  reflex  element  under  these  con- 
ditions. On  the  other  hand,  neuralgias  in  certain 
nerve  tracts  may  incite  neuralgias  elsewhere  as 
through  the  sympathetic  vibrations  of  musical 
strings. 

How  is  A  NEURALGIA  TO  BE  RECOGNIZED? — As  re- 
gards the  diagnosis  of  neuralgias  as  such,  the  recog- 
nition of  the  fact  that  a  pain  corresponds  topo- 
graphically to  a  peripheral  sensory  nerve  tract,  and 
like  this  exhibits  a  linear  rather  than  a  diffuse  dis- 
tribution, is  frequently  sufficient  to  establish  the 
nature  of  the  case.  Naturally  it  is  not  enough  to 
determine  only  the  spatial  limits  of  the  spontaneous 
pain,  but  the  presence  of  painful  pressure  points 
should  also  be  sought  for.  This  is  the  more  impor- 


THE   NERVOUS   SYSTEM  87 

tant  since  in  this  way  latent  neuralgic  conditions 
not  manifesting  themselves  spontaneously  may  be 
detected — for  example,  the  tenderness  to  pressure 
of  the  brachial  plexus  on  the  left  or  both,  sides  in 
angina  pectoris.  The  pressure  points  usually  corre- 
spond to  those  portions  of  the  nerves  which  are  sub- 
ject to  trauma  through  their  superficial  position,  a 
firm  or  bony  substructure,  etc.,  but  as  these  are  not 
constant  there  is  little  wisdom  in  overloading  the 
memory  with  ballast  of  this  nature  and  anatomical 
knowledge  is  the  best  guide.  In  addition  to  the  me- 
chanical factor  of  pressure,  traction  may  be  used 
for  evoking  the  pain  experimentally.  This  is  true 
for  the  trigeminal  nerve  (movement  of  the  lower 
jaw),  the  occipitalis  major  (rotation  of  the  head), 
and  the  sciatic  nerve  (flexion  at  the  hip  joint  with  ex- 
tended knee) .  The  susceptibility  to  influence  in  this 
way  may  also,  however,  lead  to  confusion  with 
muscle,  joint,  or  bone  pains,  and  caution  is  necessary 
in  interpreting  the  results.  The  anatomical  unity 
of  the  pain  may  be  entirely  upset  through  the  in- 
volvement of  bone,  periosteum,  muscle,  and  joint 
nerves  in  the  neuralgic  process,  and  these  possibili- 
ties must  always  be  reckoned  with.  Paroxysmal 
onset  (frequently  at  night)  is  a  common  characteris- 
tic of  neuralgic  pains.  At  any  rate,  the  mere  fact 
of  nocturnal  occurrence  does  not  justify  the  con- 
clusion that  syphilis  is  the  underlying  factor, 
although  in  general  the  absence  of  nightly  exacerba- 
tions may  be  used  with  some  probability  as  being 
against  syphilis.  The  periodical  onset  of  the  pain 


88  PAIN 

and  its  relief  by  quinine  may  find  its  explanation  in 
the  malarial  nature  of  the  neuralgia,  but  this  is  not 
necessarily  so. 

SITE  OF  THE  LESION,  WHETHER  CENTRAL  OB 
PERIPHERAL. — After  a  painful  condition  has  been 
identified  as  a  neuralgia,  it  is  always  necessary  to 
determine  the"  site  of  the  lesion.  The  possibility  of 
cerebrospinal  localization  (brain  tumor,  tabes, 
syringomyelia,  syphilitic  spinal  meningitis,  etc.) 
must  always  be  thought  of,  and  the  reflexes  and 
possible  disorders  of  motility,  like  flaccid  or  spastic 
paralysis,  ataxia,  vesical  or  rectal  disturbances, 
should  be  considered.  After  determining  the 
peripheral  character  of  the  neuralgia  the  question 
of  etiology  arises,  and  in  regard  to  this  reference 
may  be  made  to  the  classification  given  above.  It 
is  of  the  greatest  practical  importance  not  to  over- 
look a  beginning  new  growth,  to  think  of  the  possi- 
bility of  cardiac  or  aortic  lesions,  and  to  guard 
against  failure  to  recognize  some  dyscrasic  factor 
by  careful  examination  of  the  urine.  The  possi- 
bility of  reflex  origin  must  also  always  be  given  due 

weight. 

THE  FACE. 

In  order  to  determine  the  causative  factor  in 
cases  of  trigeminal  neuralgia,  the  course  of  the 
nerve  from  the  Gasserian  ganglion  onward  should 
always  be  kept  in  mind,  so  that  such  conditions  as 
tumors  of  the  nerve  itself,  aneurysms  of  the  internal 
carotid,  destructive  processes  of  the  meninges  and 
at  the  base  of  the  skull,  like  tuberculosis,  syphilis, 


THE   NERVOUS   SYSTEM  89 

carcinoma,  actinomycosis,  etc.,  may  not  be  over- 
looked. The  distribution  of  the  nerve  must  also 
be  considered  and  the  processes  in  the.  eye,  teeth, 
alveolar  cavities,  nose,  ear,  etc.,  that  may  come  in 
question.  In  infectious  processes  the  discovery  of 
pronounced  tenderness  at  the-  point  of  emergence 
of  the  supra-orbital  nerve  suggests  influenza,  typhoid 
fever,  or  malaria.  Under  these  conditions,  however, 
as  well  as  in  meningitis,  it  should  not  be  forgotten 
that  the  pain  on  pressure  may  be  only  a  part  of  the 
general  hypersBsthesia.  Of  the  reflex  etiological 
factors,  reference  may  be  made  particularly  to  the 
stagnation  of  fecal  masses  and  disorders  of  the 
female  genital  system.  There  is  no  doubt  that  at 
times,  as  in  cases  of  headache,  a  laxative  is  the  best 
antineuralgic  remedy.  Similar  conditions  also  ob- 
tain, both  in  trigeminal  neuralgia  and  in  headache, 
in  regard  to  the  general  pathological  conditions,  as 
is  not  surprising  when  one  considers  that  the  dura 
mater  is  supplied  in  part  by  the  trigeminal  nerve. 
The  underlying  conditions  that  give  rise  to  the 
symptom  complex  of  angina  pectoris  must  also  be 
counted  among  the  reflex  visceral  factors.  It  is 
true,  however,  that  isolated  trigeminal  neuralgia  is 
unusual  under  these  circumstances,  although  unilat- 
eral radiation  in  the  districts  of  the  third  and  second 
branches,  with  pain  in  the  teeth,  is  not  of  excep- 
tional rarity.  It  seems  to  me  that  there  is  a  possi- 
bility of  the  radiation  occurring  through  the  vascu- 
lar channels,  perhaps  owing  to  spasmodic  conditions 
due  to  the  sclerosis. 


90  PAIN 

THE  OCCIPITAL  REGION  AND  NAPE  OF  THE  NECK. 

Of  the  sensory  tracts  supplying  this  region  there 
may  be  mentioned,  toward  the  midline  the  occipitalis 
major,  more  laterally  the  occipitalis  minor,  and  still 
further  outward  supplying  the  posterior  surface  of 
the  ear,  the  auricularis  magnus.  Diseases  of  the 
vertebral  column  and  of  the  meninges  of  the  cervical 
portion  of  the  cord  have  a  particular  etiological 
bearing.  Since  the  second  cervical  nerve — whose 
posterior  branches,  as  the  occipitalis  major  nerve, 
supply  sensory  filaments  to  the  skin  of  the  occipital 
region — passes  between  the  atlas  and  axis,  the  occur- 
rence of  mechanical  injuries  in  this  region  may  be 
readily  understood  through  the  great  mobility  of 
the  parts.  At  the  same  time,  the  fact  is  explained 
that  neuralgia  of  this  region  may  restrict  the  move- 
ments of  the  head,  although  the  muscles  and  joints 
themselves  are  not  involved.  Neuralgias  in  this 
situation  are  probably  also  caused  mechanically  in 
cases  of  elevation  of  the  intracranial  pressure,  espe- 
cially when  due  to  processes  encroaching  on  the  pos- 
terior cerebral  fossa,  as  in  hydrocephalus  following 
serous  meningitis  (Quincke)  or  due  to  chlorosis  or 
tumors  of  the  posterior  fossa. 

Of  the  visceral  diseases  chronic  nephritis  seems 
to  me  to  be  particularly  prone  to  give  rise  to 
occipital  neuralgia,  perhaps  through  intracranial 
elevations  of  pressure.  In  addition,  glandular  proc- 
esses (lymphosarcoma)  and  more  rarely  aneurys- 
mal  dilatations  of  the  vertebral  artery  may  come 
in  question. 


THE  NERVOUS  SYSTEM  91 

THE  ARM. 

The  neuralgias  occurring  in  the  brachial  plexus 
and  involving  especially  the  ulnar  and  radial  dis- 
tricts, may  be  caused  either  through  direct  or  reflex 
factors. 

1.  Direct  Causation. — In  addition  to  spinal  dis- 
orders like  tabes,  syringomyelia,  etc.,   one  should 
think  of  vertebral  disease,  supraclavicular  or  axil- 
lary compression  by  glands,  aneurysmal  dilatations 
of  the  subclavian  or  innominate  arteries,  and  the 
presence  of  cervical  ribs.     The  brachial  plexus  may 
also  be  directly  involved  in  cases  of  inflammatory 
processes  or  malignant  growths  of  the  apical  pleura, 
and  in  this  way  spontaneous  brachial  neuralgia — 
or  at  least  tenderness  of  the  plexus — may  result. 
I  have  formerly  directed  attention  to  this  symptom 
of    "unilateral    plexus    tenderness"    in    incipient 
phthisis,   and  have  frequently  made  use  of  it  to 
good  advantage.    Abnormal  exhaustion  of  the  nerve 
tracts  through  local  overexertion,  as  in  piano  play- 
ing, must  also  be  kept  in  mind. 

2.  Reflex  Causation. — The  neuralgic  conditions 
of  the  brachial  plexus,  whether  spontaneously  pain- 
ful or  existing  only  as  a  latent  neuralgia  manifest- 
ing itself  by  tenderness  on  pressure,  may  overstep 
the  purely  neurological  limits  since  they  not  rarely 
are    accompanying    evidences    of   visceral    lesions. 
Sometimes,  though  less  often,  they  present  a  certain 
degree  of  independence,  or  may  be  accompanied  by 
mild  motor  manifestations  of  a  paretic  or  spasmodic 


92  PAIN 

nature.  A  neuropathic  constitution  undoubtedly 
affords  a  favorable  soil  for  radiations  of  this  sort. 
The  thoracic  viscera,  particularly  the  heart,  peri- 
cardium, and  large  vessels,  as  well  as  the  diaphragm 
and  the  abdominal  organs  coming  in  contact  with  it, 
are  likely  to  be  concerned  in  this  way.  The  side  of 
the  organic  lesion  then  usually  corresponds  to  the 
side  of  the  plexus  neuralgia.  There  is  no  doubt  that 
the  phrenic  nerve  is  the  reflex  tract  in  many  such 
cases,  and  therefore  tenderness  over  the  third  and 
fourth  spinous  processes  should  always  be  looked 
for. 

Particular  emphasis  may  be  laid  on  the  fact  that 
sometimes  spontaneous  pain  may  be  absent  while 
the  pressure  tenderness  is  constant,  as  in  angina 
pectoris  or  perisplenitis.  In  discussing  the  separate 
organic  pains,  these  reflex  arm  and  shoulder  neural- 
gias will  be  explained  in  detail,  and  in  order  to 
avoid  repetition  reference  is  made  to  the  sections 
in  question. 

INTERCOSTAL  SPACES,  INCLUDING  THE  UPPER  ABDOMEN. 

The  intercostal  nerves,  whose  lower  branches 
send  sensory  fibres  also  to  the  upper  portion  of  the 
abdominal  wall,  very  frequently  cause  spontaneous 
pain,  but  still  more  often  occasion  tenderness  to 
pressure.  In  addition  to  localized  central  processes 
like  spondylitis,  tabes,  syringomyelia,  etc.,  it  is  espe- 
cially internal  diseases  that  are  accompanied  by 
either  tenderness  or  spontaneous  pain  in  the  regions 
supplied  by  the  intercostal  nerves. 


THE   NERVOUS  SYSTEM  93 

Diseases  of  the  lung,  and  particularly  of  its 
pleural  covering,  deserve  first  place  in  this  connec- 
tion. In  nearly  all  cases  of  pneumonia  and  pleurisy 
the  intercostal  spaces  are  sensitive  to  pressure,  nota- 
bly in  the  axillary  region,  although  it  must  remain 
an  open  question  whether  the  tenderness  does  not 
depend  on  direct  mechanical  trauma  to  the  inflamed 
pleura  and  whether  there  may  not  also  coexist  an 
inflammatory  condition  of  the  intercostal  muscula- 
ture transmitted  through  the  lymphatics.  It  is  sug- 
gestive that  the  tenderness  in  cases  of  pulmonary 
infarct  and  tuberculosis  frequently  corresponds  ex- 
actly to  the  site  of  the  infarct  or  infiltration,  and 
shows  no  relation  to  the  usual  pressure  points  of 
intercostal  neuralgia.  Suppurative  pleural  exu- 
dates  are  likely  to  be  accompanied  by  special 
tenderness,  while  pleural  processes  accompanied 
by  contraction  only  rarely  give  rise  to  severe 
neuralgias. 

Diseases  of  the  circulatory  apparatus,  such  as 
mitral  stenosis,  are  frequent  causes  of  intercostal 
neuralgia.  Usually  the  pain  is  located  on  the  left 
side  in  the  neighborhood  of  the  apex  beat.  The 
mode  of  origin  of  intercostal  neuralgia  in  dilatation 
of  the  aorta  and  mediastinal  new  growths  demands 
no  explanation;  no  doubt  in  addition  to  direct 
trauma  reflex  stimuli  also  come  into  question  just 
as  for  the  brachial  plexus,  especially  for  the  upper 
intercostal  spaces.  The  aneurysmal  neuralgias  of 
direct  causation  are  not  rarely  characterized  by 
dependence  on  exercise  and  position,  owing  to 


94  PAIN 

stronger  pulsation  of  or  dislocation  of  the  sac.  Dis- 
eases of  the  subdiaphragmatic  organs  like  choleli- 
thiasis, perihepatitis,  pyloric  ulcer,  and  perisple- 
nitis  are  also  prone  to  cause  tenderness  of  the  axil- 
lary portions  of  the  lower  intercostal  spaces  on  the 
corresponding  side.  If  the  liver  or  spleen  is  in- 
volved the  area  of  tenderness  often  coincides  with 
the  dulness,  and  this  may  be  of  diagnostic  impor- 
tance. Here,  no  doubt,  reflex  stimuli  are  concerned 
similar  to  those  causing  the  hypersesthesia  of  cer- 
tain spinous  processes  that  is  frequently  also 
present.  In  pyloric  ulcer  and  cholelithiasis  this 
tenderness  to  pressure  and  percussion  often  occurs 
over  the  twelfth  thoracic  vertebra.  In  cases  of  sud- 
den intense  intercostal  neuralgia  the  imminent 
onset  of  herpes  zoster  should  be  thought  of. 

THE  FLANKS  AND  LOWER  ABDOMINAL  REGION. 

Leaving  aside  the  neuralgias  of  spinal  origin 
which  have  already  been  spoken  of  several  times, 
idiopathic  conditions  of  this  sort  are  rare  in  the 
present  regions.  Of  the  intra-abdominal  causes, 
retroperitoneal  processes  such  as  glandular  masses, 
aneurysm  of  the  abdominal  aorta,  and  renal  diseases 
at  once  suggest  themselves.  The  renal  causes  in- 
clude tumors  pressing  on  the  nerve  trunks  passing 
over  the  posterior  surface  of  the  organ,  inflamma- 
tory and  suppurative  processes,  or  perinephritic 
cicatrization  following  infarct,  etc. 

Another  etiological  factor  is  formed  by  hernias 
which  may  induce  neuralgia  through  pressure  along 
the  hernial  canal. 


THE   NERVOUS   SYSTEM  95 

LOWER  EXTREMITIES. 

1.  Anteriorly  and  Internally  (Crural  Nerve). — 
Pain  of  the  same  linear  distribution  as  that  of  neu- 
ralgia may  sometimes  be  caused  by  phlebitic  proc- 
esses in  the  internal  saphenous  vein.    It  may  also 
be  the  result  of  femoral  hernia  and  may  stand  in 
relation  to  diseases  of  the  kidney  such  as  nephro- 
lithiasis,  and  of  the  appendix.    Beyond  this,  refer- 
ence may  be  made  to  the  general  underlying  causes 
of  neuralgic  pain  (v.  classification  on  page  85). 

2.  Externally. — The  neuralgias  occurring  in  the 
district  of  the  external  cutaneous  nerve,  and  there- 
fore involving  the  external  and  posterior  surface 
of  the  thigh  from  the  iliac  crest  to  the  knee,  are  not 
usually  founded  on  causative  factors  specific  for  the 
locality.     The  etiological  possibilities  coincide  with 
those  of  neuralgia  in  general,  and  therefore  include 
trauma,  gout,  syphilis,  tabes,  pernicious  anaemia,  etc. 
As  the  nerve  traverses  a  fibrous  canal  in  the  fascia 
lata  of  the  thigh,  it  is  not  astonishing  that  tension  of 
this  structure,   such  as  is  caused  on  standing  or 
walking,  easily  produces  exacerbations  of  the  pain, 
whereas  rest  brings  relief. 

3.  Internally. — Neuralgias  involving  the*  region 
of  the  adductors  of  the  thigh  always  suggest  the 
presence  of  a  possibly  incarcerated  obturator  hernia, 
especially  if  the  thigh  cannot  be  approached  to  the 
midline. 

4.  Posteriorly.    (The  sciatic  plexus.) — The  pain 
that  is  principally  concerned  under  this  heading  is 
linear  in  distribution  and  often  extends  down  the 


96  PAIN 

entire  posterior  side  of  the  lower  extremity.  Even 
the  laity  usually  interpret  this  correctly  as  a  "  nerve 
pain."  If  there  is  in  addition  tenderness  over  the 
course  of  the  nerve  and  pain  on  stretching  it  by 
forcible  flexion  at  the  hip  with  extended  knee,  there 
is  little  room  for  doubt.  Diseases  of  the  hip  joint 
differ  in  that  flexion  of  the  hip  is  painful  even  when 
the  knee  is  kept  flexed.  It  is  the  duty  of  the 
physician  not  to  rest  content  with  the  diagnosis  of 
sciatica,  which  may  already  have  been  made  by  the 
patient,  but  to  investigate  the  particular  source  of 
the  trouble,  and  here  as  in  neuralgias  in  general  I 
think  that  I  may  formulate  the  rule:  If  nothing  is 
found,  search  further.  The  scheme  of  causes  given 
above  may  serve  to  aid  in  the  general  task  of  orien- 
tation. Examination  of  the  rectum  and  vagina 
should  never  be  omitted  in  order  that  any  possible 
pelvic  lesions,  such  as  new  growths  of  the  intestine 
or  pelvic  bones,  may  be  detected,  and  the  patient's 
general  condition  (emaciation,  etc.)  should  be  care- 
fully considered. 

The  degree  of  fulness  of  the  rectum  should  also 
be  taken  into  account;  there  is  no  doubt  that  a 
connection  exists  between  fecal  stagnation  and  pain 
in  the  sciatic  plexus,  though  it  is  difficult  to  ex- 
press an  opinion  in  regard  to  the  details  of  the 
relationship.  Usually  the  condition  is  merely  a  pre- 
disposing and  not  a  causative  factor.  Before  decid- 
ing to  accept  the  assumption  of  a  purely  mechanical 
direct  action  of  fecal  masses  on  the  nerve  plexus,  it 
is  advisable  to  think  of  the  association  that  may 


THE  NERVOUS  SYSTEM  97 

exist  between  headache  or  trigeminal  neuralgia  and 
constipation,  and  of  the  fact  that  fecal  accumula- 
tions probably  also  serve  to  increase  pain  through 
the  interference  with  venous  return  (vasa  ner- 
vorum).  The  possible  existence  of  external  or  inter- 
nal varicosities  (involving  the  nerve  sheath)  with 
phlebitic  or  thrombotic  processes  must  always  be 
thought  of.  In  this  respect  conditions  are  of  course 
much  more  unfavorable  in  the  lower  extremities 
than  in  the  upper.  Bilateral  pain  always  suggests 
median  lesions  involving  the  vertebral  column  or 
spinal  cord,  or  diffuse  dyscrasic  disorders  like  dia- 
betes. Pain  of  maximum  intensity  that  is  refrac- 
tory to  all  treatment  sometimes  is  encountered  in 
tumors  of  the  cauda  equina.  A  careful  examination 
of  the  nervous  system,  with  special  attention  to  the 
tendon  reflexes  of  the  lower  extremities,  bladder  dis- 
turbances, atrophies,  etc.,  should  never  be  omitted. 

NEURALGIAS   INVOLVING  THE  SYMPATHETIC 
SYSTEM  AND  THE  VAGUS. 

A  priori  the  assumption  suggests  itself  that  the 
neuralgic  manifestations  just  described  for  the 
cerebrospinal  system  may  also,  in  the  presence  of 
the  corresponding  etiological  factors,  occur  in  the 
separate  portions  of  the  sympathetic  system  and  the 
viscera  supplied  by  it.  This  view  is  fully  confirmed 
by  the  clinical  observations.  The  task  of  correctly 
interpreting  visceral  neuralgias  of  this  sort  is,  of 
course,  much  more  difficult.  In  this  case  one  is  deal- 
ing not  with  the  anatomically  distinct,  simply  con- 

7 


98  PAIN 

stmcted,  and  directly  accessible  nerve  tracts  of  the 
cerebrospinal  nervous  system,  but  with  plexuses  and 
groups  of  ganglia  for  the  most  part  inaccessible  to 
physical  examination.  The  problem  is  further  com- 
plicated by  the  fact  that  the  separate  networks  have 
as  end  stations  organs  like  the  stomach,  intestine, 
ureter,  genitals,  etc.,  in  which  painful  lesions  may 
originate  primarily.  Theoretically  three  possibili- 
ties may  be_  considered  and  in  practice  these  are 
shown  to  be  well  founded. 

(a)  Simple    Neuralgia.  —  The    pain-producing 
process  is  a  neuralgic  condition  in  one  of  the  im- 
portant tracts  of  the  vegetative  nervous  system,  and 
the    corresponding    organ    is    anatomically    intact. 
Gastric  crises  may  be  regarded  as  an  example  of 
this  sort  and  a  pendant  in  the  province  of  the 
cerebrospinal  system  would  be  neuralgia  of  the  sec- 
ond and  third  branches  of  the  trigeminal  nerve 
without  any  disease  of  the  teeth. 

(b)  Simple  Organic  Pain. — The  pain  has  exactly 
the  same  character  in  regard  to  localization,  quality, 
accompanying  manifestations,  etc.,  but  is  the  result 
of  an  anatomical  or  functional  disorder  of  the  organ 
itself.     As  a  paradigm  reference  may  be  made  to 
the  pain  of  gastric  ulcer.    Recently  an  attempt  has 
been  made  to  argue  away  the  existence  of  stomach 
pains  as  such  and  to  regard  the  cause  of  every 
gastric  pain  as  being  a  sympathetic  neuralgia.    This 
is  entirely  inadmissible  and  in  opposition  to  the  facts 
of  clinical  observation.    One  has  only  to  think  of 
the  stomach-ache  that  is  promptly  checked  by  a  dose 


THE   NERVOUS  SYSTEM  99 

of  alkali  or  by  the  administration  of  local  anaes- 
thetics such  as  anaesthesin  or  cocaine.  The  same 
thing  is  true  of  pyloric  stenosis,  and  the  explanation 
offered  by  the  advocates  of  the  theory  just  men- 
tioned to  the  effect  that  the  sympathetic  nerves  are 
compressed  by  the  distended  stomach  is  extremely 
improbable.  The  existence  of  true  gastralgia,  re- 
sulting from  purely  local  anatomical  and  functional 
disturbances,  is  as  certain  as  the  occurrence  of  pain 
in  dental  caries. 

(c)  Mixed  Forms. — I  believe  that  a  combined 
form  of  visceral  pain  is  not  at  all  rare  in  which  both 
the  sensory-conducting  tract  and  the  organ  in  ques- 
tion play  a  distinct  role  in  the  causation  of  the  pain ; 
as  an  example,  trigeminal  neuralgia  and  painful 
dental  caries  may  be  mentioned.  Such  a  combined 
origin  of  pain  in  the  sympathetic  and  vagus  districts 
is  probably  commoner  than  is  ordinarily  supposed, 
particularly  in  neuropathic  individuals.  It  is  con- 
ceivable that  the  anatomically  or  functionally  active 
organic  process  might  arise  only  secondarily  as  the 
result  of  atrophic  disturbance  due  to  a  primary 
neuralgic  condition,  but  the  reverse  is  also  probable, 
as  well  as  coincident  causation.  When  such  mixed 
forms  of  visceral  neuralgia  are  in  question,  it  is 
clear  that,  to  continue  the  example  chosen  above, 
the  extraction  of  the  decaying  tooth  may  bring  relief 
commensurate  with  its  component  of  painful  sen- 
sation, but  the  pain  will  continue  as  long  as  the 
neuralgic  condition  of  the  trigeminus  does  not  im- 
prove. In  the  same  way,  in  other  cases  of  mixed 


100  PAIN 

form,  the  same  attacks  of  pain  may  recur  after  the 
removal  of  gallstones  or  the  treatment  of  a  pyloric 
stenosis  by  gastro-enterostomy.  Through  exact 
analysis  of  the  conditions,  as  well  as  the  study  of 
the  psychical  make-up  of  the  patient,  it  is  possible 
from  case  to  case  to  interpret  these  mixed  forms 
correctly  and  to  determine  approximately  the  rela- 
tive proportions  of  the  two  components.  The  prog- 
nostic and  therapeutic  importance  of  an  analysis  of 
this  sort  is  self-evident. 

ETIOLOGY. — As  far  as  the  etiological  sources  of 
the  visceral  neuralgias  are  concerned  it  may  be  said 
that  there  is  a  far-going,  deep-seated  correspondence 
between  the  cerebrospinal  and  sympathetic  nervous 
systems.  In  this  connection  reference  may  be  made 
to  the  scheme  of  causes  given  above  as  well  as  to  the 
section  on  gastralgia. 

HOW  MAY  A  VlSCEEAL  NEUKALGIA  BE  EECOGNIZED? 

The  diagnosis  of  a  visceral  neuralgia  is  probably 
one  of  the  most  difficult  of  differential  problems  and 
can  never  be  made  with  absolute  certainty,  as  it  is 
nearly  always  a  diagnosis  by  exclusion.  For  ex- 
ample, what  is  known  concerning  the  positive  symp- 
toms of  a  neuralgia  of  the  cosliac  plexus  is  so  inade- 
quate and  so  vague  that  a  conscientious  clinician 
would  never  venture  to  make  this  diagnosis  directly. 
The  cause  of  pain  induced  by  deep  pressure  over  the 
abdomen  is  difficult  to  determine.  Whoever  is 
anxious  to  discover  tenderness  to  pressure  of  the 
sympathetic  fibres  or  of  the  solar  plexus  will  usually 
succeed  in  doing  so !  If  the  psychical  equilibrium  is 


THE   NERVOUS  SYSTEM  101 

intact,  there  is  no  neuropathic  tendency,  and  etiologi- 
cal  factors  of  the  variety  in  question  are  absent,  one 
should  be  very  reluctant  to  think  of  a  visceral  neural- 
gia. But  in  this  neurasthenic  age  cases  that  comply 
with  these  requirements  are  very  rare,  while  on  the 
other  hand,  even  serious  nervous  disturbances  do  not 
exclude  the  possibility  of  an  organic  lesion  as  the 
basis  of  the  pain,  the  more  so  as  they  may  be  second- 
ary. The  important  general  rule  of  unity  of  etiology 
in  disease  is  open  to  many  exceptions  in.  this  prov- 
ince, and  painful  states  due  to  a  combination  of 
functional  and  anatomical  components  are  certainly 
very  numerous. 

TOPOGRAPHY. — The  topography  of  the  pain  usu- 
ally has  no  differential  significance.  The  distri- 
bution of  the  pain  in  a  neuralgia  of  the  ureter  de- 
pending on  chronic  lead  poisoning  is  the  same  as  that 
caused  by  the  passage  of  a  concretion,  and  hysteri- 
cal angina  pectoris  radiates  in  the  same  way  as  the 
true  organic  type.  Essential  gastralgias,  it  is  true, 
are  rarely  asymmetrical  in  their  localization,  in  con- 
trast to  the  pain  of  ulcer  and  pyloric  stenosis,  and 
this  is  particularly  true  of  the  tenderness  to  pres- 
sure. Gastric  crises,  however,  with  their  tendency 
to  a  left-sided  localization,  at  least  so  far  as  the 
spontaneous  pain  is  concerned,  form  an  exception 
to  the  rule. 

MODIFYING  FACTORS. — A  careful  study  of  these  is 
always  of  great  importance.  Whenever  reflex  in- 
volvement is  evident,  as,  for  example,  in  cases  of 
gastric  pain  at  the  time  of  menstruation,  it  is  per- 


102  PAIN 

missible  to  think  of  a  simple  visceral  neuralgia,  but 
it  should  not  be  forgotten  that  the  pain  of  ulcer  or 
biliary  and  appendicular  colic  may  be  induced 
through  the  profoundly  disturbing  process  of  men- 
struation. In  general,  it  may  be  regarded  as  posi- 
tive evidence  of  the  existence  of  a  pronounced  func- 
tional component  if  a  sedative  regime  comprising 
general  hygiene  and  psychical  rest,  the  diversion  of 
the  attention,  and  administration  of  quieting  drugs 
like  the  bromides  or  valerian,  has  a  notable  and  per- 
sistent effect  on  the  intensity  and  frequency  of  the 
pain.  On  the  other  hand,  it  is  fair  to  assume  a 
prominent  local  component  when  purely  topical 
treatment  like  the  administration  of  alkali  in  gastric 
pain  is  promptly  effective.  Serious  consideration 
must  be  accorded  to  mechanical  factors  and  their 
effect.  If  a  given  position  of  the  body  always  causes 
prompt  increase  in  the  pain,  it  is  natural  to  think 
of  a  localized  anatomical  lesion  of  the  organ  in 
question  (cf.  p.  22).  The  most  exhaustive  physical 
and  functional  examination  of  the  organ  that  appar- 
ently is  involved  and  the  consideration  of  its  secre- 
tions or  excretions  is  of  course  of  the  greatest 
importance  in  reaching  a  decision. 


CHAPTER  VI. 

ORGANS  OF  MOTION. 

I.  JOINT  PAINS  OR  ARTHRALGIAS. 
TOPOGRAPHY. — In  view  of  the  clearness  of  the 
topographical  relations  and  the  ease  of  accurate 
functional  examination,  it  is  ordinarily  not  difficult 
to  identify  an  arthralgia  as  such.  Only  when  the 
joints  concerned  are  difficult  of  access,  like  those  of 
the  vertebral  column  or  of  the  sacro-iliac  synchon- 
drosis,  or  are  abnormal  (manubrium-corpus),  are 
difficulties  to  be  expected.  Sometimes,  however,  the 
topographical  considerations  themselves  may  lead 
astray,  as  an  illustration  of  which  may  be  cited  the 
pain  in  the  knee  that  so  often  precedes  coxitis  in 
young  persons.  On  the  other  hand,  it  is  always  our 
duty  not  to  remain  satisfied  with  the  general  diag- 
nosis of  arthralgia  but  to  determine  which  anatomi- 
cal component  of  the  articulation  is  the  seat  of  the 
pain.  Accordingly,  the  articular  extremities  of  the 
bones,  the  fibrous  capsule,  the  neighboring  tendons 
and  tendon  sheaths,  and  adjoining  muscles  must  all 
be  tested  as  regards  painfulness.  The  examination 
must  include  all  structures  standing  in  anatomical 
relationship  to  the  joint  capsule,  such,  for  example, 
as  burssB,  nerve  trunks,  vessels,  or  fibromas  in  the 
subcutaneous  tissues.  It  is  also  necessary  to  distin- 
guish between  deep-seated  and  superficial  pain. 
Functional  arthralgias  of  the  sort  that  sometimes 

103 


104  PAIN 

occur  in  neuropathic  individuals  are  not  rarely  ac- 
companied by  marked  cutaneous  hyperaesthesia  with- 
out deep-seated  tenderness,  so  that  in  functional 
coxalgia  forcible  pressure  of  the  head  of  the  femur 
against  the  acetabulum  is  easily  borne,  although 
even  gentle  touching  of  the  skin  gives  rise  to  pain. 

In  general  it  may  be  said  that  arthralgias  do  not 
radiate.  The  necessary  conducting  tracts  are  want- 
ing, a  condition  in  contrast  to  the  joint  pains  of 
neuralgic  origin,  such  as  the  shoulder  pain  of  angina 
pectoris.  An  exception  to  this  rule  is  formed  by 
coxalgia;  in  this  the  pain  may  radiate  down  the 
thigh  toward  the  knee.  The  same  thing  is  true  for 
the  ankle  joint  in  flat  foot.  In  other  articular 
conditions  radiation  is  generally  to  be  expected  only 
in  cases  of  neuritic  or  spinal  complications,  such  as 
tabes  or  syringomyelia,  or  if  the  pain  is  purely 
functional  in  nature. 

INTENSITY. — Assuming  a  normal  nervous  system, 
the  severity  of  the  pain  seems  to  depend  on  the 
degree  of  acuteness  in  onset  as  well  as  the  intensity 
of  the  inflammatory  process,  and  therefore  many 
cases  of  acute  polyarthritis,  gonorrhoeal  joint  affec- 
tions, and  gout  are  highly  painful.  When  the  ner- 
vous system  is  in  a  state  of  hypersensitiveness 
(hysteria)  a  disproportion  may  be  observed  between 
the  objective  conditions  and  the  subjective  sensa- 
tions, but  this  by  itself  may  not  be  sufficient  to  ex- 
clude the  organic  nature  of  the  affection.  Where, 
however,  the  pain-conducting  tract  is  damaged,  as  in 
tabes  and  syringomyelia,  one  must  be  prepared  to  en- 


ORGANS  OF  MOTION  105 

counter  very  slight  degrees  of  pain  or  even  the  total 
absence  of  this  symptom  in  spite  of  anatomical 
changes  of  considerable  extent,  and  this  discrepancy 
may  direct  the  attention  into  the  proper  channel. 

KELATIONS  IN  REGARD  TO  TIME. — The  relation  of 
joint  pains  to  time  can  be  made  use  of  only  with 
great  caution  in  differential  diagnosis.  The  occur- 
rence of  nocturnal  exacerbations  is  frequently 
pointed  out  in  cases  depending  on  syphilis  in  the 
secondary  or  tertiary  stages.  The  absence  of  noc- 
turnal increase  may  in  general  render  syphilis  less 
likely,  but  its  presence  is  far  from  rare  in  non- 
syphilitic  conditions  also,  and  may  occur  often 
enough  in  cases  of  ordinary  acute  polyarthritis  and 
especially  in  gouty  arthralgias.  Only  the  functional 
arthralgias  of  neuropathic  nature  seem  never  to  be 
accompanied  by  nocturnal  increase  in  pain.  The 
occurrence  of  arthralgias  during  pregnancy  or  in  the 
puerperium  always  suggests  gonorrhoea  (lighting  up 
of  old  foci)  or  sepsis. 

MODIFYING  FACTORS. — Among  the  most  important 
characteristics  of  a  joint  pain  is  its  susceptibility 
to  mechanical  influences.  These  may  vary  in  nature, 
and  the  two  most  important  are  (1)  pressure  in  the 
neighborhood  of  the  joint  (effect  on  the  bone  ends, 
capsule,  etc.) ;  (2)  active  and  passive  motion. 

1.  In  examining  joints,  particularly  when  the 
larger  ones  are  involved,  one  should  never  omit  to 
investigate  the  possibility  of  a  bone  process,  such 
as  tuberculosis,  syphilis,  or  osteomyelitis,  as  the 
underlying  cause  of  the  joint  affection,  and  for  this 


106  PAIN 

purpose  the  articular  extremities  of  the  bones  should 
be  carefully  palpated  and  be  pressed  against  each 
other.  No  less  care  should  be  used  in  examining 
the  fibrous  capsule  and  tendon  sheath. 

2.  The  production  of  pain  through  active  and 
passive  motion  is  of  course  one  of  the  chief  evidences 
of  an  arthralgia.  It  should  be  remembered,  how- 
ever, that  motion  of  a  joint  may  also  give  rise  to  pain 
through  traction  on  inflamed  muscles,  nerve  trunks, 
or  vessels  (e.g.,  the  shoulder  pain  in  aortalgia)  with- 
out there  being  any  lesion  of  the  articulation  itself. 
If,  however,  even  slow  motion  of  very  slight  extent 
causes  pain  the  diagnosis  of  arthralgia  receives 
greater  justification.  These  are  cases  in  which  im- 
mobilization of  the  joint  is  the  best  analgesic,  but  in 
functional  arthralgias  fixation  is  very  badly  borne. 
This  fact  may  be  of  differential  diagnostic  value  as 
well  as  the  noteworthy  difference  between  superficial 
and  deep  tenderness.  The  mechanical  factor  of 
trauma  may  be  the  inciting  agent  of  both  functional 
and  organic  arthralgias. 

THERAPEUTIC  INFLUENCES. — The  mechanical  fac- 
tors are  supplemented  in  their  action  by  chemical 
agents.  This  is  especially  the  case  from  the  thera- 
peutic standpoint,  but  may  also  be  made  use  of  in 
differential  diagnosis.  Only  in  exceptional  cases  are 
gonorrhoeal  joint  affections  and  the  arthralgias  of 
rheumatoid  arthritis  and  gout  favorably  influenced 
by  the  salicylates.  Mercury  and  iodine  again 
are  particularly  effective  in  cases  of  syphilitic 
arthralgias. 


ORGANS  OF  MOTION  107 

ACCOMPANYING  MANIFESTATIONS. — Not  rarely  the 
pain  may  be  practically  the  only  manifestation  of 
the  joint  affection,  and  this  is  not  exclusively  the 
case  in  functional  arthralgias,  but  may  occur  in 
organic  lesions.  The  harmful  agents  attacking  the 
joints  may  also  invade  the  muscular  and  nervous 
systems  (neuritis),  and  such  complications  must  be 
thought  of  in  testing  for  tenderness  on  pressure. 
Possible  involvement  of  the  bones,  as  in  syphilitic 
periostitis,  the  growth  of  osteophytes,  erosion  of  the 
articular  surfaces,  etc.,  must  be  thought  of.  Where 
fever  is  an  accompanying  symptom  the  bacteriologi- 
cal cause  of  this  should  be  determined  if  possible  and 
efforts  be  made  to  discover  the  primary  focus  of  in- 
fection. This  may  be  sought  for  in  the  tonsils,  acces- 
sory nasal  cavities,  the  middle  ear,  the  urethra,  pros- 
tate, parametrium,  etc.  Particular  attention  should 
of  course  also  be  given  to  endo-,  peri-  and  myocardial 
changes. 

ETIOLOGY. — In  the  foregoing  the  recognition  of 
an  arthralgia  as  such  has  been  discussed,  and  from 
a  consideration  of  the  facts  elicited  in  this  way  much 
light  will  often  be  thrown  on  the  etiology  of  the 
process.  A  definite  conclusion  in  this  regard  can 
of  course  be  arrived  at  only  from  a  complete  investi- 
gation of  the  disease  process.  To  begin  with,  the 
adoption  of  the  following  classification  is  suggested : 

1.  Arthralgias  of  infectious  origin:   a,  acute;  b, 
chronic. 

2.  Arthralgias  due  to  disorders  of  metabolism. 

3.  Arthralgias  of  neurogenous  nature. 


108  PAIN 

1.  The  streptococci  require  special  consideration 
under  this  head  as  the  inciters  of  the  ordinary  acute 
polyarthritis,  or  of  sepsis.  Other  organisms  of 
importance  are  gonococci  and  the  pus-producing 
cocci  in  general  (staphylococci,  diplococci,  and  men- 
ingococci),  and  of  less  frequent  occurrence — ex- 
cepting the  tubercle  bacillus — bacilli  such  as  'those 
of  typhoid  fever,  dysentery,  leprosy,  and  influenza. 
Diseases  like  scarlatina,  variola,  parotitis,  and 
syphilis  are  also  to  be  thought  of  in  this  connection. 

2.  Under  this  heading  are  grouped  the  arthri- 
tides  of  the  uratic  diathesis  and  its  variants,  the 
arthritis  of  lead  poisoning,  and  the  joint  processes 
sometimes  accompanying  psoriasis,  as  well  as  many 
cases  of  chronic  polyarthritis,  although  in  these  the 
possibility  of  an  infectious  etiology  must  always  be 
kept  in  mind.     The  cases  of  intermittent  hydrops  of 
the  knee  and  the  joint  conditions  of  haemophilia  may 
also  be  included  in   this   class.    The  position   of 
arthritis  deformans  is  not  yet  clear. 

3.  The  arthralgias  of  neurogenic  nature,  such  as 
those  of  tabes  and  syringomyelia  are  ordinarily  char- 
acterized by  slight  intensity  which  may  diminish  to 
almost  nothing.     They  therefore  offer  a  striking  con- 
trast  to   the   arthralgias    sometimes    occurring   in 
neuropathic  individuals  and  forming  an  articular 
manifestation  of  hysteria. 

II.  MUSCULAR  PAINS  OR  MYALGIAS. 

Tenderness  on  pressure  over  a  muscle  and  pain 
whick  is  increased  on  passive  stretching  or  active 
contraction,  form  the  most  important  indications  for 


ORGANS  OF   MOTION  109 

the  diagnosis  of  a  myalgia.  In  dealing  with  the 
extremities  and  with  the  musculature  of  the  head  and 
neck  the  problem  does  not  ordinarily  present  great 
difficulties,  providing  that  there  are  no  painful  in- 
flammatory conditions  of  the  overlying  skin  and 
subcutaneous  tissues. 

SOUBCES  OF  ERROK. — It  is  hardly  necessary  to 
point  out  how  puzzling  it  may  be  to  interpret  cor- 
rectly pain  in  the  region  of  the  diaphragm.  Diffi- 
culties may  also  be  encountered  in  investigating  the 
musculature  of  the  chest,  the  back,  and  abdomen, 
since  functional  examination  may  not  give  satisfac- 
tory results  or  may  be  hard  to  carry  out,  and  the 
pain  on  pressure  may  be  referable  to  underlying 
organs.  In  this  regard  it  is  important,  particularly 
in  dealing  with  the  abdominal  muscles,  to  ascertain 
whether,  when  the  muscle  is  in  a  state  of  contraction, 
it  is  equally  or  even  more  tender.  If  the  sensitive 
point  is  situated  beneath  the  muscles  a  decrease  or 
disappearance  of  the  tenderness  may  be  expected, 
as  the  contracted  muscle  yields  but  little  to  the  pres- 
sure. Reference  may  also  be  made  at  this  point  to 
the  myalgias  frequently  occurring  in  laborers 
through  muscular  fatigue  or  the  effects  of  exposure. 
These  are  particularly  frequent  in  the  thoracic 
muscles,  and  as  the  pain  is  increased  by  respiration 
owing  to  the  functions  of  the  muscles  involved,  sus- 
picion of  pleural  processes  is  easily  aroused.  In 
these  cases  it  is  important  if  possible  to  raise  _the 
muscle  from  its  underlying  structures  and  test  it  for 
tenderness  by  taking  it  between  two  fingers.  In  gen- 


110  PAIN 

eral  the  tenderness  is  increased  when  the  muscle  is 
contracted.  I  should  also  like  to  call  attention  to  the 
tenderness  of  the  abdominal  muscles,  particularly 
in  the  epigastrium,  which  is  not  uncommon  after 
severe  protracted  coughing,  as  in  phthisis.  If  there 
happen  to  be  at  the  same  time  abdominal  symptoms 
such  as  gastric  disorders,  diarrhoea,  etc.,  confusion 
may  easily  arise  and  the  pain  of  gastric  ulcer  or 
peritoneal  irritation  be  thought  of.  The  same  thing 
is  true  in  regard  to  myalgia  coming  on  acutely  after 
the  lifting  of  heavy  loads,  which  may  persist  for 
months.  In  cases  in  which  the  diseased  muscle  be- 
longs to  the  deeper  layers,  e.g.,  the  deep  muscles 
of  the  neck,  diagnostic  difficulties  may  present  them- 
selves, and  there  is  danger  of  confounding  the  con- 
dition with  a  bone  lesion. 

GENERAL,  PATHOLOGY  AND  ETIOLOGY. — In  discuss- 
ing the  general  pathology  of  muscular  pain,  the  fact 
must  be  emphasized  that  the  chief  site  of  the  sensa- 
tion is  probably  to  be  found  less  in  the  parenchyma 
than  in  the  connective  tissue  framework.  This  is 
most  highly  developed  in  the  tendons  and  aponeu- 
roses,  and  the  pain  may  extend  to  these,  so  that  in 
considering  the  myalgias  these  structures  must  also 
be  taken  into  account.  The  pain  of  cramp,  such  as 
that  of  the  calves  of  the  legs,  is  etiologically  among 
the  most  easy  to  understand.  In  this  the  purely 
mechanical  factor  of  pressure  is  concerned,  a  form 
of  pain  mechanism  that  is  also  encountered  in  organs 
composed  of  unstriped  muscular  fibre,  like  the  intes- 
tine and  uterus.  Otherwise  inflammatory  processes 


ORGANS  OF  MOTION  111 

are  the  most  fundamental  causes  of  myalgias,  both 
those  of  endogenous  nature  due  to  disorders  of 
metabolism  and  those  of  exogenous  origin  depending 
on  toxins  in  general,  and  especially  those  of  bacterial 
nature.  The  myalgias  that  are  more  or  less  physio- 
logical in  nature  and  follow  over-exertion  through  the 
accumulation  of  fatigue  toxins  may  also  be  grouped 
in  the  class  of  endogenous  origin.  It  must  always  be 
taken  into  account  that  the  real  cause  of  the  myalgia 
may  be  found  extramuscularly  in  a  primary  painful 
affection  of  the  peripheral  nervous  system,  such  as 
neuritis,  provided  that  sensory  intramuscular  fibres 
are  involved;  an  example  of  this  is  the  tenderness 
to  pressure  of  the  calves  of  the  legs  of  drunkards. 

MODIFYING  FACTOES. — As  has  already  been 
pointed  out  tenderness  is  an  important  aid  in  the 
diagnosis  of  myalgia.  It  must  be  ascertained 
whether  this  symptom  is  locally  limited  or  is  diffuse 
throughout  the  muscle  and  tendon.  Local  lesions 
such  as  traumatic  or  spontaneous  haematomas, 
abscesses,  tubercles,  gummas,  muscular  cicatrices, 
echinococcus  cysts,  new  growths,  etc.,  frequently  are 
characterized  by  local  tenderness.  Where  the  mus- 
cular inflammation  is  diffuse,  as  the  result  of  infec- 
tion or  through  causes  of  a  general  type,  the  tender- 
ness will  also  be  diffuse  in  nature.  Such  a  condition 
might  be  due  to  infection  with  the  pus-producing 
cocci,  acute  infectious  polyarthritis,  typhoid  fever, 
influenza  or  gonorrhoea.  Other  processes  that  may 
be  mentioned  are  intestinal  autointoxication,  Unver- 
richt's  dermatomyositis,  haemorrhagic  myositis,  and 


1 12  PAIN 

parasitic  diseases,  especially  trichinosis.  In  contra- 
distinction to  the  neuralgias  spontaneous  exacerba- 
tions of  pain  are  very  rare ;  the  symptom  is  caused 
through  pressure,  or  active  and  passive  motion.  Of 
other  modifying  influences  climatic  conditions  such 
as  dampness,  draughts,  etc.,  may  be  mentioned,  par- 
ticularly in  connection  with  myalgias  localized  in  the 
muscles  of  the  shoulder,  neck,  and  lumbar  region. 
If  the  process  is  situated  in  the  muscles  of  respira- 
tion the  movements  of  deep  breathing,  coughing, 
sneezing,  defecation,  etc.,  give  rise  to  pain.  The 
same  is  true  of  swallowing  if  the  muscles  of  deglu- 
tition are  involved.  Of  therapeutic  influences  men- 
tion may  be  made  especially  of  the  effect  of  salicy- 
lates  and  preparations  of  iodine  and  mercury. 

ETIOLOGY. — Owing  to  the  great  variety  of  the  proc- 
esses giving  rise  to  myalgias,  it  is  difficult  to 
arrange  them  in  a  scheme  of  classification.  The 
distinction  of  most  service  in  differentiation  is  be- 
tween, on  the  one  hand,  the  type  running  its  course 
as  a  local  and  afebrile  condition,  and  on  the  other, 
the  type  diffuse  in  nature  and  presenting  the  picture 
of  a  severe  infectious  disease. 

1.  MUSCULAK  AFFECTIONS  CHIEFLY  LOCAL  IN  NATUKE. 

Traumatic  hasmatomas  and  hernias  of  muscle 
(the  adductor  group) ;  haematomas  following  pre- 
ceding vascular  damage  (typhoid  fever,  sepsis, 
phosphorus  poisoning,  arsenic  poisoning,  jaundice, 
etc.) ;  rheumatic  affections  due  to  cold,  for  ex- 
ample, in  the  shoulder  or  lumbar  aponeurosis ;  mus- 


ORGANS   OF   MOTION  113 

cular  cicatrices  following  fibrous  myositis  through 
local  venous  thrombosis,  for  example,  deep-seated 
varicosities  in  the  muscles  of  the  calves;  atheroma 
of  the  muscular  arteries  (intermittent  claudication) ; 
muscular  abscesses  and  infarcts,  gummas,  tubercles, 
echinococcus  cysts,  new  growths. 

2.  MUSCULAR  AFFECTIONS  CHIEFLY  DIFFUSE  IN 

NATUKE. 

1.  In  general  infectious  processes  through  pus 
organisms,    acute    articular    rheumatism,    typhoid 
fever,    influenza,    syphilis,    etc.,    Unverricht's    der- 
matomyositis,     haemorrhagic     polymyositis,     acute 
delirium. 

2.  In  constitutional  disorders,  such  as  the  rheu- 
matic diathesis  and  ossifying  myositis.     The  latter 
is  unlikely  after  the  twentieth  year. 

3.  In  parasitic  diseases,  particularly  trichinosis. 

4.  Periarteritis  nodosa.     This  is  most  often  seen 
between  the  twentieth  and  thirtieth  years. 

DIFFERENTIAL  DIAGNOSIS. — As  has  already  been 
pointed  out  the  diagnosis  of  myalgia  in  general  is 
founded  on  the  symptoms  of  tenderness  to  pressure 
and  of  increase  in  pain  on  active  and  passive  motion. 
Alterations  in  the  volume  and  consistency  of  the 
structures  concerned  have  a  corroborative  value,  but 
are  not  a  conditio  sine  qua  non  for  the  diagnosis. 
If  the  symptoms  mentioned  are  noted  as  well  as  the 
absence  of  spontaneous  exacerbations  the  danger  of 
confusion  with  neuralgia  is  ordinarily  not  very 
great.  It  is  well  to  keep  in  mind  the  pains  that  are 


114  PAIN 

often  associated  with  the  milder  states  of  weakness ; 
for  example,  in  the  shoulder  girdle  in  cases  of  aortic 
disease,  processes  in  the  liver  and  spleen,  or  in  apical 
tuberculosis.  The  connection  of  lesions  of  the  kid- 
ney, such  as  calculus  and  new  growths,  as  well  as  of 
the  prostate  or  parametrium  (metastasis  of  carci- 
noma), with  pain  in  the  thigh,  also  deserves  con- 
sideration. Involvement  of  the  neck  muscles  may 
simulate  meningeal  rigidity  or  spondylitis,  though 
the  contrast  between  the  intensity  of  the  apparent 
stiffness  of  the  neck  and  the  absence  of  other  menin- 
geal symptoms,  and  especially  the  tenderness  of  the 
muscles,  will  guard  against  error.  Similar  consid- 
erations will  serve  to  exclude  tetanus  when  the 
muscles  of  mastication  come  in  question.  In  differ- 
entiating between  pleural  pain  and  rheumatoid  affec- 
tions of  the  thoracic  muscles  the  chiefly,  and  often 
exclusively,  axillary  localization  of  the  former  seems 
to  me  to  be  of  significance.  In  order  to  guard 
against  mistakes  it  is  always  advisable  to  pay  par- 
ticular attention  to  the  presence  of  tenderness  of 
nerve  trunks  and  of  joints,  and  it  should  be  remem- 
bered that  the  simultaneous  occurrence  of  disease  in 
these  structures  is  not  impossible. 

ACCOMPANYING  MANIFESTATIONS. — In  addition,  the 
temperature  and  the  general  condition  should  receive 
careful  scrutiny.  Serious  illness  with  typhoid-like 
symptoms  suggests  the  not  rarely  fatal  cases  of 
Unverricht's  dermatomyositis  whose  etiology  is  still 
uncertain,  haemorrhagic  polymyositis,  or  in  the  pres- 
ence of  the  appropriate  initial  intestinal  symptoms, 


ORGANS   OF  MOTION  115 

trichinosis.  In  the  latter  case',  the  combination  of 
multiple  myalgia  with  eosinophilia  is  of  particular 
importance.  The  presence  of  cutaneous  oedema  is 
also  significant.  It  is  brawny  and  firm,  with  non- 
involvement  of  the  joints  in  Unverricht's  dermato- 
myositis,  and  involves  the  eyelids  in  trichinosis.  If 
the  swelling  is  limited  to  one  lower  extremity,  local 
thrombotic  conditions  come  in  question,  such  as  those 
occurring  in  the  cachexia  of  malignant  disease  or  as 
post-infectious  complications. 

III.  BONE  PAINS  OR  OSTALGIAS. 

The  danger  of  misinterpreting  pain  caused  by  the 
irritation  of  sensory  fibres  in  the  bone-marrow  and 
periosteum  and  of  ascribing  to  it  a  different  nature 
(rheumatic  or  neuralgic)  is  shown  by  experience  to 
be  no  slight  one.  This  is  in  part  explained  by  its 
comparative  rarity,  and  in  addition  there  is  no  dis- 
tinct localization  in  the  affected  part,  particularly  in 
diffuse  skeletal  disease,  such  as  osteomalacia,  new 
growths  of  the  bone-marrow,  etc.  Furthermore,  as 
far  as  the  factor  of  motion  is  concerned,  the  symp- 
toms correspond  to  those  of  many  commoner  and 
therefore  better  known  painful  conditions.  For  ex- 
ample, if  the  bone  exhibits  periosteal  changes  at  the 
point  of  insertion  of  muscular  masses,  contractions 
in  these  will  naturally  be  painful  and  there  will  be 
danger  of  confusion  with  muscle  or  joint  pain. 
Spontaneous  exacerbations,  which  may  be  nocturnal 
in  character  and  occur,  for  example,  in  osteomalacia, 
new  growths  of  the  bone-marrow,  and  post-typhoid 


116  PAIN 

osteomyelitis,  may  simulate  neuralgic  or  spinal 
processes,  and  this  the  more  so  if  alteration  in  gait, 
increased  reflexes,  etc.,  are  present,  as  in  osteo- 
malacia.  If  one  further  reflects  that  infectious  and 
dyscrasic  factors,  as  well  as  malignant  processes, 
play  a  particularly  important  role  in  the  etiology  of 
ostalgias,  it  is  to  be  expected  a  priori,  that  compli- 
cating muscle,  joint,  and  nerve  pains  may  appear 
both  primarily  and  secondarily.  From  this  it  is  easy 
to  understand  that  errors  in  diagnosis  may  readily 
occur. 

ETIOLOGY. — It  is  advisable  to  begin  by  passing  in 
review  the  various  general  and  specific  disease 
processes  associated  with  bone  pain. 

1.  Infectious  processes,  such  as  typhoid  fever,  in- 
fluenza, sepsis,  etc.  The  lesions  of  the  bone-marrow 
in  these  conditions  may  be  manifold  in  nature  and 
run  through  all  the  stages  from  simple  hypersemia 
to  fibrous  exudation,  necrosis,  and  the  formation  of 
specific  granulation  tissue  such  as  a  gumma  or  a 
tubercle.  The  scale  of  subjective  pain  sensations 
corresponds  to  this  range  of  anatomical  changes, 
running  the  gamut  from  slight  pain  evoked  only 
through  strong  pressure  to  the  most  severe  spon- 
taneous paroxysms.  Usually  the  primary  lesions 
run  their  course  in  the  bone-marrow  itself  and  the 
periosteal  involvement  is  secondary,  although  the 
possibility  of  an  initial  affection  of  the  latter  cannot 
be  excluded. 

The  infectious  process  may  be  principally  or 
entirely  localized  in  the  bone-marrow  and  give  rise 


ORGANS   OF  MOTION  117 

to  local,  exceedingly  intense  pain  (acute  osteomye- 
litis), or  the  lesions  may  be  very  slight  and  be  dis- 
covered only  when  special  search  is  made  for  them. 
For  example,  in  the  course  of  typhoid  fever  and  far 
into  the  convalescence  it  is  wise  not  only  to  watch 
for  spontaneous  ostalgia  (often  manifesting  noc- 
turnal exacerbations),  but  also  to  look  for  tender- 
ness in  the  portions  of  the  skeleton  frequently  in- 
volved in  osteomyelitis  of  this  type.  These  are  par- 
ticularly the  tibia,  ribs,  femur,  and  clavicle,  and 
especial  attention  should  be  given  to  the  epiphyseal 
regions.  The  bone  processes  due  to  syphilis  and 
tuberculosis  and  the  ostalgias  associated  with  them 
fall  within  the  province  of  the  surgeon,  and  are 
therefore  only  mentioned.  Tenderness  pointing  to 
irritation  of  the  bone-marrow,  particularly  in  the 
sternum,  is  not  infrequently  encountered  in  infec- 
tious processes  like  malaria  and  pneumonia  if  it  is 
looked  for,  and  the  ostitic  symptoms  sometimes  ob- 
served in  biliary  cirrhosis  may  also  be  placed  in  this 
class.  Some  of  the  cases  at  least,  of  Marie's  hyper- 
trophic  osteoarthropathy,  associated  with  clubbed 
fingers,  may  be  included  in  the  same  group,  in  so  far 
as  they  occur  in  empyema  of  the  pleural  cavities. 
The  status  of  the  disease  of  mother-of-pearl  workers 
is  still  uncertain. 

2.  New  growths,  involving  especially  the  bones 
of  the  trunk  and  of  the  proximal  portions  of  the 
extremities.  This  localization  is  characteristic  for 
the  more  or  less  diffuse  lesions  of  the  bony  frame- 
work, such  as  multiple  myeloma,lymphadenia  ossium, 


118  PAIN 

ehloroma,  etc.,  which  therefore  exhibit  somewhat  the 
course  of  an  internal  disease.  The  correct  interpre- 
tation of  the  not  uncommon  pain  in  these  conditions 
is  an  essential  for  the  early  recognition  of  the  true 
state  of  affairs.  This  is  no  less  true  for  the  cases 
of  metastatic  new  growths  which  are  often  associated 
with  neoplasms  of  the  breast,  prostate,  thyroid,  and 
adrenal  body.  Given  a  history  of  the  removal  of  a 
carcinoma  of  the  breast  even  some  years  previously, 
the  occurrence  of  indefinite  pain  always  suggests  the 
possibility  of  ostalgia.  Paradoxical  as  it  may  sound, 
it  is  precisely  the  indeterminate  nature  of  a  pain 
that  suggests  the  possibility  of  its  originating  in  the 
bone. 

3.  Blood  diseases.  It  is  very  tempting  to  explain 
the  tenderness  in  the  lower  part  of  the  sternum  that 
is  so  often  observed  in  the  grave  blood  diseases  like 
pernicious  anaemia,  myelogenous  leukaemia,  and 
pseudo-leukaemia  as  being  associated  with  hyperas- 
mic  and  inflammatory  changes  in  the  bone-marrow. 
Sometimes  this  symptom  is  one  of  the  earliest  sub- 
jective disturbances.  On  leaning  against  the  edge 
of  the  table  in  writing,  on  resting  against  the  win- 
dow sill,  or  in  bending  over  the  washtub,  the  patients 
experience  pain  in  the  portion  of  the  sternum  pressed 
upon,  and  on  examination  pronounced  tenderness  is 
discovered,  particularly  in  the  lower  half  of  the  bone. 
An  interesting  observation  is  that  the  sternal  pains 
are  controlled  by  arsenic,  and  as  I  have  convinced 
myself  in  numerous  cases,  are  least  troublesome  dur- 
ing the  acme  of  the  drug's  action.  In  the  myeloge- 


ORGANS   OF   MOTION  119 

nous  forms  of  leukaemia  they  may  run  parallel  to  the 
rise  and  fall  in  the  number  of  leucocytes.  These 
pains  never  occur  spontaneously,  but  are  always 
produced  only  by  pressure  over  the  lower  half  of  the 
sternum.  In  exceptional  cases  there  is  also  tender- 
ness in  other  portions  of  the  skeleton,  like  the 
humerus  or  ilium. 

4.  Dyscrasias.  Bone  diseases  of  dyscrasic  and 
trophic  nature.  For  the  sake  of  completeness  ref- 
erence may  be  made  to  the  extremely  rare  condition 
of  ostitis  deformans  (Paget)  and  of  leontiasis  ossea 
(Virchow).  The  pains  occurring  about  the  head  in 
cases  of  the  latter  are  probably  neuralgic  in  origin 
rather  than  ostalgias,  and  are  due  to  pressure  on 
the  nerves  through  the  proliferation  of  bone.  In 
acromegaly  ostalgia  is  not  ordinarily  observed  and 
the  condition  may  be  dismissed  with  simple  mention. 

OSTEOMALACIA. — In  this  disease  ostalgia  appears 
in  its  purest  and  most  concentrated  form.  It  must 
always  be  our  aim  to  make  the  correct  diagnosis  at  a 
time  before  palpable  changes  in  the  skeleton  have 
developed,  but  this  is  rendered  possible  only  by 
familiarity  with  the  initial  pain  symptoms.  The 
lumbar  region  and  the  lower  extremities  are  usually 
indicated  by  the  patients  as  the  chief  seats  of  dis- 
comfort, at  least  in  the  puerperal  forms.  Whenever 
pains  having  this  localization  appear  in  the  course  of 
a  pregnancy  the  possibility  of  a  beginning  osteo- 
malacia  should  be  thought  of.  In  contradistinction 
to  the  pain  due  to  neuralgic  disorders  or  spinal 
affections,  like  myelitis,  the  pains  of  osteomalacia 


120  PAIN 

usually  subside  completely  during  rest,  and  their 
onset  is  intimately  connected  with  mechanical  fac- 
tors. Active  and  passive  movement,  coughing, 
laughing,  sneezing,  yawning,  etc.,  either  become  im- 
possible or  cause  pain,  even  in  far  distant  parts  such 
as  the  lower  extremities.  Active  motion,  such  as 
walking,  stooping,  and  rising  after  being  seated  for 
some  time,  usually  causes  the  patients  great  discom- 
fort. On  getting  out  of  bed  they  carefully  lift  out 
each  leg  in  turn,  holding  by  the  thigh.  Deep  respira- 
tion often  gives  rise  to  pain  in  the  ribs,  and  descend- 
ing^ stairs  is  sometimes  still  more  uncomfortable  than 
the  ascent  owing  to  the  jarring  of  the  body  that  it 
occasions.  While  moving  about  is  exceedingly 
arduous,  remaining  in  the  same  position  for  any 
length  of  time,  either  sitting  or  lying,  results  in  an 
increase  of  the  pain,  so  that  the  patients  are  obliged 
to  change  their  position  constantly,  and  sleep  is 
therefore  very  broken.  The  movement  of  abduction 
at  the  hip  joint  is  particularly  prone  to  cause 
paroxysms  of  pain,  as  well  as  rapid  dorsal  flexion 
at  the  ankle  joint.  In  the  latter  case  a  pain  is  not 
rarely  caused  which  runs  the  entire  length  of  the 
lower  extremity,  radiating  to  the  pelvis  and  some- 
times accompanied  by  dorsal  clonus.  Lateral  com- 
pression of  the  thorax,  or  of  the  pelvis  at  the  level 
of  the  trochanters  or  the  iliac  crests,  promptly  causes 
pain.  Wearing  a  corset  and  tight  lacing  sometimes 
appear  to  relieve  the  subjective  symptoms,  evidently 
through  the  support  given  to  the  spinal  column. 


ORGANS  OF  MOTION  121 

It  is  clear  that  the  mechanical  factors  influencing 
the  pain  of  osteomalacia  are  not  deficient  in  charac- 
teristic qualities.  If  in  spite  of  this,  confusion  with 
other  affections,  particularly  those  of  rheumatic 
nature,  is  not  rare,  this  may  partly  be  explained  by 
the  fact  that  to  some  extent  they  respond  in  the  same 
way  to  therapeutic  measures.  My  experience  leads 
me  to  speak  of  the  prompt  relief  to  pain  afforded  by 
the  diaphoresis  caused  by  hot-air  baths,  as  well  as 
of  the  improvement  often  spontaneously  occurring 
during  the  hot  summer  months.  Complications  such 
as  myalgias  of  the  adductors  and  calves,  joint  pains 
of  arthritic  nature,  and  neuralgias  like  sciatica  also 
sometimes  occur  and  may  contribute  to  render  the 
picture  of  typical  osteomalacia  indistinct  as  regards 
its  pain  phenomena.  As  suggested  above,  accom- 
panying symptoms  like  ankle  clonus,  together  with 
the  apparent  weakness  of  the  lower  extremities,  may 
even  give  rise  to  confusion  with  spinal  affections. 
The  intimate  relationship  between  the  pain  of  osteo- 
malacia and  mechanical  factors  like  motion,  as 
opposed  to  the  more  spontaneous  onset  of  the 
paroxysms  of  spinal  pain,  should  be  sufficient  for  the 
purposes  of  differentiation.  The  absence  of  bladder 
disturbances  is  also  an  important  diagnostic  point. 
The  differentiation  from  spondylitis  in  the  dorso- 
lumbar  region  with  secondary  neuralgia  of  the  pel- 
vis— in  which  I  have  found  that  there  may  also  be 
tenderness  of  the  pelvic  bones  owing  to  involvement 
of  the  perio  steal  nerves — is  ordinarily  not  difficult. 
It  is  sufficient  to  think  of  this  possibility  in  order  to 


122  PAIN 

avoid  error  by  a  careful  examination  of  the  spinal 
column.  Where  typical  bony  changes  already  exist 
an  extended  analysis  of  the  pain  phenomena  may  of 
course  be  dispensed  with.  In  its  onset,  however,  the 
disease  belongs  to  the  subjective  ostalgias  discussed 
above. 

FUNCTIONAL  OSTALGIAS. — It  may  be  assumed 
a  priori  in  view  of  the  analogous  observations  in  the 
province  of  joint  and  muscle  pains  that  ostalgias 
may  sometimes  appear  as  manifestations  of  a  gen- 
eral neurosis,  like  hysteria.  In  fact,  there  are  obser- 
vations on  record  showing  the  possibility  of  the 
simulation  of  osteomalacia  by  that  great  artist  in 
imitation,  hysteria.  In  such  cases  error  is  to  be 
avoided  by  a  careful  study  of  all  the  attendant  symp- 
toms, but  it  must  be  borne  in  mind  that  the  existence 
of  hysteria  does  not  exclude  osteomalacia  and  that 
the  latter  disease  in  a  hysterical  subject  will  present 
confusing  symptoms  due  to  this  tendency. 

REFLEX  OSTALGIAS. — Reflex  sensitiveness  to  pres- 
sure and  percussion  over  the  spinal  column  may 
occur  in  abdominal  processes  without  any  anatomical 
lesion  of  the  bone  itself.  This  is  particularly  the 
case  in  gastric  ulcer  and  cholelithiasis,  in  which  the 
hyperalgetic  spot  is  often  over  the  twelfth  dorsal 
vertebra  at  the  level  of  the  lower  pulmonary  border, 
or  in  the  interscapular  space.  The  local  tenderness 
to  pressure  and  percussion  sometimes  exhibited  by 
areas  of  the  skull  overlying  cortical  cerebral  tumors 
may  be  due  to  slight  degrees  of  periostitic  irritation 
(internal  erosion). 


CHAPTER  VII. 

DIGESTIVE  SYSTEM. 

GASTRALGIAS. 

IN  this  section  those  paroxysms  of  pain  are  to  be 
described  which  are  colicky  in  nature,  are  localized 
in  the  epigastrium,  are  frequently  accompanied  by 
objective  gastric  symptoms,  such  as  vomiting,  eruc- 
tations, etc.,  and  which  in  the  absence  of  anatomical 
disease  of  the  stomach  are  usually  interpreted,  and 
misinterpreted,  as  "nervous  gastralgia." 

GENEKAL  PATHOGENESIS. — In  view  of  the  negative 
nature  of  the  condition,  it  is  not  astonishing  that 
even  the  existence  of  gastralgia  as  a  painful  sensa- 
tion arising  in  the  stomach  itself  is  sometimes  denied, 
and  the  sensation  in  question  is  assumed  to  arise 
entirely  outside  of  the  organ  in  the  vagus  and  sym- 
pathetic nerve  tracts.  According  to  this  view  gas- 
tralgia would  be  sharply  differentiated  from  the 
pains  occurring  in  other  muscular  hollow  viscera, 
such  as  the  gall-bladder,  intestine,  ureter,  uterus, 
etc.,  and  would  be  brought  into  association  with  the 
neuralgias.  For  the  same  reason  that  it  would  be 
improper  in  the  case  of  a  tumor  of  the  Gasserian 
ganglion,  accompanied  by  pain  in  the  teeth,  to  speak 
summarily  of  toothache,  the  term  gastralgia  should 
be  avoided  and  be  supplanted  by  the  expression 
sympathetic  or  vagus  neuralgia,  with  the  addition 
of  the  underlying  cause.  In  analogy  to  the  condi- 

123 


124  PAIN 

tions  existing  in  neuralgias  of  the  cerebrospinal 
nervous  system  the  occurrence  of  tenderness  along 
the  nerve  tracts  in  question,  the  vagus,  the  sympa- 
thetic nerves,  and  the  solar  plexus  might  be  ex- 
pected. It  is  clear,  however,  that  owing  to  the  topo- 
graphical relations  tenderness  to  pressure  in  the 
neck  or  over  the  anterior  surface  of  the  spinal 
column,  in  the  abdomen,  etc.,  is  far  from  comparable 
in  diagnostic  value  to  the  demonstration  of  distinct 
tenderness  over  the  sciatic  nerve,  for  example,  and 
it  is  especially  necessary  under  these  circumstances 
not  to  allow  the  wish  to  become  father  to  the 
observation. 

Of  course  the  occurrence  of  gastralgia  is  per- 
fectly possible  as  a  purely  neuralgic  disturbance  in 
the  course  of  the  sensory  tracts  without  the  exist- 
ence of  any  causative  motor  or  secretory  disorders 
in  the  organ  itself.  This  is  especially  the  case  when 
the  attacks  of  pain  persist  even  when  the  stomach 
is  empty  and  are  not  influenced  by  alkalies,  local 
anaesthetics,  or  the  ingestion  of  food.  The  gastric 
crises  of  tabes  may  serve  as  a  paradigm  of  this 
group,  and  the  similar  conditions  appearing  in 
syringomyelia,  multiple  sclerosis,  cerebrospinal 
syphilis,  vagus  lesions,  etc.,  may  also  be  pointed 
out. 

VAGUS  GASTRALGIA. — For  example,  in  a  case  of 
gastric  crises  under  my  observation,  the  patient  was 
able  to  cut  short  mild  attacks  by  inserting  the  finger 
deeply  into  the  left  external  auditory  meatus  (vagus 


DIGESTIVE   SYSTEM  125 

fibres),  but  the  act  was  accompanied  by  violent 
coughing.  Starting  with  this  observation  of  the 
patient's,  to  the  effect  that  it  was  possible  to  inhibit 
the  painful  process — evidently  situated  in  the  left 
vagus — by  a  sort  of  counter-stimulation  such  as  is 
applicable  to  the  act  of  sneezing,  I  prescribed  with 
good  effect  the  application  to  the  left  auditory 
meatus  of  a  pledget  of  cotton  moistened  with  a  mix- 
ture consisting  of  three  drops  of  oil  of  mustard,  one 
gram  of  menthol  and  ten  grams  of  liquid  petrolatum. 
It  would  be  interesting  to  repeat  this  experiment 
in  other  cases  of  suspected  vagus  gastralgia. 

GASTRALGIAS  OF  GASTRIC  ORIGIN. — In  addition  to 
these  gastralgias  which  are,  so  to  speak,  extra- 
stomachic,  there  are  also  undoubted  essential  gas- 
tralgias which  probably  preponderate,  and  in  which 
the  underlying  cause  is  formed  by  the  motor  element ; 
that  is,  pyloric  spasm  alone  or  in  combination  with 
coincident  dilatation  of  the  gastric  wall  at  the  antrum 
of  the  pylorus,  as  well  as  secretory  disturbances  such 
as  hyperacidity  and  acid  hyperaesthesia.  From  the 
latter  point  of  view  especially,  the  alkali  test  should 
be  made  in  every  case  of  gastralgia  by  giving  a  pinch 
of  sodium  bicarbonate  during  the  attack.  This  test 
is  of  value  in  differentiating  the  various  gastralgias, 
but  even  in  case  prompt  relief  is  afforded  it  must  be 
remembered  that  the  effect  may  be  the  result  of  the 
combined  action  of  various  factors. 

ETIOLOGY. — The  causes  of  gastralgia  may  be 
classified  as  follows : 


126  PAIN 

I.  IKRITABLE  WEAKNESS  OF  THE  NERVOUS  SYSTEM. 

This  factor  is  in  most  cases  the  fundamental 
cause  of  the  essential  gastralgias.  Without  the  in- 
creased susceptibility  to  pain  that  it  involves,  no 
doubt  many  of  the  special  factors,  for  example  those 
of  alimentary  nature,  would  be  inadequate  to  cause 
actual  painful  phenomena.  In  these  cases  the  appli- 
cation of  the  therapeutic  lever  is  particularly  effec- 
tive, and  improvement  may  often  be  secured  even 
in  the  persistence  of  the  specific  cause  of  the  pain. 
The  most  varied  influences  and  processes  may  com- 
bine to  produce  the  condition  of  irritable  weakness 
of  the  nervous  system,  mental  overexertion,  psychi- 
cal emotions,  sexual  aberrations,  anaemias,  the  arthri- 
tic diathesis,  chronic  infections  such  as  tuberculosis 
with  possible  secondary  sympathetic  and  adrenal 
lesions,  syphilis,  chronic  intoxications  such  as  nico- 
tinism, plumbism,  alcoholism,  arsenic  poisoning,  etc. 
These  conditions  contribute  their  part  in  giving  rise 
to  essential  gastralgias ;  they  are  factors  that  occur 
also  in  the  causation  of  neuralgias  in  the  cerebro- 
spinal  nervous  system  (cf.  classification  on  p.  85). 
Frequently  they  simply  prepare  the  soil  for  the 
subsequent  action  of  more  specific  causes. 

II.  DIRECT  CAUSES. 

A.  ACTING  CENTRALLY. — This  heading  comprises 
especially  diseases  of  the  central  nervous  system, 
such  as  tabes,  syringomyelia,  multiple  sclerosis,  cere- 
brospinal  syphilis,  etc.  It  is  difficult  to  decide  to 


DIGESTIVE   SYSTEM  127 

what  extent  disturbances  of  metabolism  such  as  the 
arthritic  diathesis,  diabetes,  and  the  chronic  infec- 
tions and  intoxications  mentioned  in  the  preceding 
paragraph,  have  a  central  or  a  peripheral  effect. 
In  this  class  may  also  be  included  the  gastralgias, 
often  accompanied  by  vomiting,  sometimes  occurring 
in  cases  of  vascular  lesions  such  as  atheroma  of  the 
abdominal  aorta,  of  the  coronary  arteries,  the  cceliac 
axis,  etc.,  and  concerning  whose  exact  mechanism 
we  are  still  ignorant. 

B.  ACTING  PERIPHERALLY. — Here  the  point  of  at- 
tack lies  in  the  sensory  nervous  apparatus  of  the 
stomach  itself.  Organic  lesions  of  the  gastric 
mucosa,  such  as  ulcerative  or  inflammatory  proc- 
esses, may  serve  to  induce  gastralgias,  especially  if 
there  is.  an  already  existing  predisposition.  The 
actual  mechanism  of  pain  production  frequently  de- 
pends on  a  pyloric  spasm  of  reflex  nature;  that  is, 
on  a  pathological  increase  in  motor  activity  which 
of  course  may  reach  its  maximum  when  there  is  a 
permanent  tendency  to  abnormal  peristalsis,  as  in 
pyloric  stenosis.  Among  the  chemical  factors — 
whose  existence  in  a  given  case  is  indicated  by  the 
prompt  temporary  effect  of  the  administration  of 
alkalies — are  to  be  counted  the  inorganic  and  organic 
acids,  contact  of  which  with  the  gastric  mucous  mem- 
brane may  induce  gastralgias  of  the  most  severe 
type.  In  view,  of  what  was  said  above  under  section 
L,  it  may  be  expected  that  in  hyperaesthesia  small 
amounts  of  acid  will  be  effective,  while  the  variety 
of  the  acid  is  also  not  without  importance. 


128  PAIN 

ACIDITY. — The  complaints  usually  ascribed  to 
hyperacidity  and  capable  of  being  modified  by  the 
administration  of  alkali  might  therefore  more  cor- 
rectly be  spoken  of  as  due  simply  to  acidity,  since 
frequently  they  result  not  from  an  excess  of  acid  but 
through  an  increased  susceptibility  to  acids.  Here 
again  those  gastralgias  might  be  mentioned  that 
sometimes  occur  with  an  anatomically  intact  stomach 
after  the  ingestion  of  strongly  acid  foods  or  those 
forming  acid  on  decomposition  (animal  fats,  milk) 
or  strong  spices,  coffee,  etc.  Mechanical  factors, 
such  as  insufficient  mastication,  overeating,  and  foods 
tending  to  gas  formation,  also  come  in  question. 

HUNGER  PAIN. — Just  as  quantitative  and  qualita- 
tive abnormalities  in  the  ingestion  of  food,  including 
poisoning,  may  lead  to  gastralgiform  attacks,  pro- 
tracted fasting  may  have  a  similar  effect.  This 
appears  rather  paradoxical,  since  apparently  noth- 
ing becomes  a  cause.  In  reality  it  is  probably  the 
physiological  increase  in  peristalsis  (growling  of  the 
empty  stomach)  that  accompanies  the  sensation  of 
hunger,  and  sometimes  perhaps  also  the  gastric  juice 
secreted  under  these  conditions  that  causes  the  pain, 
and  this  is  particularly  likely  to  occur  if  the  predis- 
position already  spoken  of  in  section  I.  exists 
or  the  stomach  has  become  a  locus  minoris  resis- 
tentia  through  ulcerative  processes  (particularly 
ulcer,  rarely  carcinoma). 

III.  REFLEX  CAUSES. 

The  gastralgias  comprised  under  this  heading  in- 
clude those  sometimes  occurring  in  diseases  of  the 


DIGESTIVE   SYSTEM  129 

appendix,  disorders  of  the  female  genital  apparatus, 
sometimes  even  in  nasal  affections,  hernias  of  the 
omentum  in  the  linea  alba,  movable  kidney,  etc.  In 
such  cases  it  is  always  necessary  to  determine 
whether  factors  from  groups  I.  and  II.  are  not  also 
concerned,  and  accordingly  one-sided  special  treat- 
ment must  be  avoided.  I  consider  it  very  probable 
that  the  epigastric  pains  often  accompanied  by  gas- 
tric symptoms  such  as  vomiting,  eructations,  the 
feeling  of  peristaltic  unrest,  etc.,  which  sometimes 
occur  in  cases  of  more  or  less  latent  gall-bladder 
disease  as  well  as  in  pancreatic  conditions  and  dis- 
eases of  the  aorta  and  coronary  arteries,  are,  as  a 
matter  of  fa,ct,  to  be  regarded  as  reflex  gastralgias. 

DIFFEKENTIAL  DIAGNOSIS. — Colicky  pains  in  the 
epigastrium  associated  with  gastric  symptoms  of 
course  always  suggest  gastralgia,  but  a  satisfactory 
diagnosis  can  be  made  only  through  the  proper  inter- 
pretation of  the  causative  factors.  For  this  purpose 
it  is  necessary  to  pass  in  review  the  possibilities  sug- 
gested under  headings  L,  II.,  and  III.,  unless  defi- 
nite peculiarities  of  the  pain  give  the  necessary  clue. 

TOPOGKAPHY  AND  TIME. — Attention  may  be  called 
to  the  purely  left-sided  character  of  the  pain  that  is 
sometimes  observed.  Biliary  colic  is  never  re- 
stricted to  the  left  half  of  the  epigastrium — leaving 
out  of  account  the  possibility  of  transposition  of  the 
viscera.  Primary  gastralgias  ordinarily  do  not 
radiate  into  the  upper  extremities,  particularly  not — 
as  opposed  to  cholelithiasis — into  the  right  shoulder 
and  arm.  Eadiation  into  the  left  upper  extremity 

9 


130  PAIN 

is  also  very  rare  as  compared  to  the  epigastric  form 
of  angina  pectoris.  For  a  consideration  of  the  ten- 
dency to  radiation  exhibited  in  the  colic  of  pyloric 
stenosis  reference  may  be  made  to  the  section  in 
question.  It  is  also  advisable  to  try  to  ascertain  the 
depth  of  the  pain  from  the  surface  in  order  to  avoid 
erroneously  interpreting  intercostal  neuralgias  in 
the  epigastrium  as  gastralgias.  For  this  reason  it 
is  always  wise  to  test  the  cutaneous  sensibility  of  the 
epigastrium.  The  regular  daily  recurrence  of  the 
attacks,  particularly  if  a  relationship  to  the  taking 
of  food  can  be  demonstrated,  suggests  the  possibility 
of  the  conditions  discussed  in  group  II.  B,  such  as 
ulcer,  pyloric  stenosis,  etc.  On  the  other  hand,  great 
irregularity  in  the  appearance  of  the  pain  points 
more  to  the  central  diseases  spoken  of  under  group 
II.  A,  and  perhaps  the  reflex  factors  of  group  III. 

MODIFYING  FACTOES. — In  order  to  avoid  errors  in 
drawing  conclusions  from  the  causative  factors,  it 
is  always  necessary  to  remember  that  these  are 
occasionally  multiple  in  nature. 

Not  without  reason  was  the  group  included  under 
the  heading  of  irritable  weakness  placed  first  in  the 
list  of  etiological  factors,  for  gastralgias  of  the  most 
varied  origin  may  be  founded  on  this  basis.  This 
indeed  is  true  of  attacks  of  pain  in  general,  and  the 
occurrence  of  a  gastralgia  under  the  influence  of 
emotional  excitement,  such  as  anger  or  grief,  is  far 
from  justifying  the  exclusion  of  an  organic  cause. 
Among  the  mechanical  factors  I  should  attach  a 
not  unimportant  role  to  the  matter  of  bodily  posi- 


DIGESTIVE  SYSTEM  131 

tion.  If  the  gastralgia  is  merely  the  result  of  func- 
tional or  organic  disease  of  the  nervous  system  the 
effect  of  position  will  in  most  instances  be  hardly 
perceptible.  The  reverse  may  be  the  case  to  a  very 
pronounced  degree,  however,  if  organic  lesions  of 
the  stomach  (II.  B)  or  reflex  stimuli  from  abnor- 
mally movable  organs  (III.)  are  concerned.  If 
gastralgic  seizures  occur  in  connection  with  rapid 
motion,  stair-climbing,  etc.,  masked  forms  of  angina 
pectoris  must  always  be  thought  of.  Pronounced 
tenderness,  particularly  on  percussion  of  the  epi- 
gastrium or  on  pressure,  renders  the  existence  of  an 
organic  condition  likely,  especially  if  asymmetrical, 
but  exceptions  in  this  regard  may  be  encountered 
both  on  the  organic  and  on  the  functional  side. 

Particular  attention  must  of  course  be  given  to 
the  effect  of  diet.  The  mechanical,  chemical,  and 
thermic  factors  concerned  in  the  ingestion  of  food 
tending  to  gas  formation,  strongly  acid,  spiced,  or 
fatty  foods,  cold  fluids,  etc.,  are  of  importance,  espe- 
cially in  dealing  with  the  organic  processes  spoken  of 
under  group  II.  B.  The  effect  of  acids  and  the 
opposite  test  with  alkalies  is  also  of  importance. 

In  the  same  way  it  seems  to  me  that  the  action  of 
local  anaesthetics,  such  as  cocaine,  alypin,  and  anass- 
thesin  is  of  importance  from  the  diagnostic  stand- 
point. If  the  administration  of  such  agents  causes 
rapid  decrease  in  the  discomfort  the  presence  of 
local  pain-producing  factors  such  as  ulcer,  carci- 
noma, haemorrhagic  erosion,  or  hyperaesthesia  of  the 
gastric  mucosa  may  be  regarded  as  demonstrated, 


132  PAIN 

and  in  making  the  otherwise  difficult  decision  be- 
tween gastric  and  duodenal  ulcer  the  prompt  produc- 
tion of  relief  in  this  way  points  in  favor  of  the 
former  lesion. 

A  possible  interdependence  between  the  onset  of 
gastric  pain  and  constipation  of  long  duration  should 
not  be  overlooked.  In  hydrochloric  acid  hyper- 
sesthesia  or  hyperacidity,  as  well  as  in  ulcer  and 
pyloric  stenosis,  there  is  no  doubt  in  regard  to  a 
connection  of  this  sort,  and  it  probably  depends  on 
interference  with  the  emptying  of  the  stomach  and 
secondary  stagnation  and  fermentation  of  its  con- 
tents. The  effect  of  menstruation  should  also  be 
considered. 

ACCOMPANYING  MANIFESTATIONS. — Although  in 
cases  of  gastralgia  the  best  advice  that  can  be  given 
is  to  make  a  complete  physical  examination  involv- 
ing all  the  organ  systems,  in  addition  to  the  analyt- 
ical study  of  the  paroxysms  in  the  manner  just 
indicated  and  keeping  in  mind  the  possibilities  sug- 
gested in  the  introductory  classification,  it  may  be 
helpful  to  emphasize  several  points  that  aid  in  rapid 
orientation,  although  not  of  great  importance  per  se. 
Among  these  may  be  mentioned  the  possible  coinci- 
dence of  bladder  disturbances  or  pains  in  the  lower 
extremities  (tabes).  The  syndrome  gastralgia  and 
distended  bladder  always  awakens  suspicion  of  gas- 
tric crises.  High  blood  pressure,  accompanied  by 
arteriosclerotic  pallor  of  the  face  and  dyspnrea,  even 
though  slight,  suggests  an  arterial  starting  point 
such  as  angina  pectoris.  Gastralgia  and  sarcinae 


DIGESTIVE  SYSTEM  133 

in  the  vomitus  or  in  the  feces  point  to  ulcerative 
stenosis  of  the  pylorus.  The  same  thing  is  true  of 
visible  gastric  pefistalsis  or  marked  gastric  meteor- 
ism  (not  to  be  confounded  with  distention  of  the 
epigastrium  through  an  enlarged  liver  in  choleli- 
thiasis). Examination  for  a  palpable  or  painful 
gall-bladder,  for  the  presence  of  a  hernia  in  the 
linea  alba,  or  for  tenderness  of  the  appendix  and 
parametrium,  should  never  be  omitted. 

GASTRIC  ULCER. 

TOPOGRAPHICAL  CONSIDERATIONS. — It  might  be 
assumed  a  priori  that  in  ulcerative  processes  of  the 
gastric  mucosa  the  pain,  whether  spontaneous  or 
produced  artificially  through  pressure  or  percussion, 
would  have  a  more  or  less  asymmetrical  left-sided 
localization  corresponding  to  the  position  of  the 
organ.  As  a  matter  of  fact,  this  is  true  in  a  large 
number  of  cases,  at  least  so  far  as  ulcers  in  the 
neighborhood  of  the  cardia  or  the  central  part  of  the 
stomach  are  concerned,  and  may  be  made  use  of  in 
differential  diagnosis.  Exclusively  or  principally 
left-sided  spontaneous  pain  or  tenderness  to  pres- 
sure, either  in  the  epigastrium  or  in  the  anterior  or 
posterior  lower  thoracic  region,  renders  painful 
processes  of  the  right  side  of  the  abdomen  and  par- 
ticularly gall-bladder  affections  improbable,  and 
therefore  limits  the  diagnostic  possibilities  from  the 
very  beginning. 

The  painful  area  to  be  outlined  by  pressure  or 
percussion  is  not  rarely  situated  on  the  left  side 


134  PAIN 

anteriorly,  just  below  the  costal  arch,  somewhat  to 
the  median  side  of  the  mammary  line.  It  is  also 
sometimes  possible  to  discover  another  point  of  ten- 
derness on  the  left  side  posteriorly,  close  to  the  verte- 
bral column,  at  about  the  level  of  the  twelfth  dorsal 
or  first  lumbar  vertebra.  Concussion  of  the  left 
lower  portion  of  the  thorax  with  the  fist  at  about 
the  level  of  the  lower  pulmonary  border  is  also  often 
exquisitely  painful  as  compared  with  the  right  side. 
Even  when  the  pain  is  median  in  onset  it  frequently 
radiates  in  the  direction  of  the  left  costal  border 
and  to  the  left  scapula.  This  is  particularly  likely 
in  cases  with  perigastritic  adhesions  to  the  dia- 
phragm, the  transmission  probably  taking  place 
through  the  phrenic  nerve  into  the  shoulder.  There 
may  then  also  be  a  pressure  point  over  the  outer  and 
middle  third  of  the  upper  border  of  the  trapezius 
muscle.  While  the  left-sided  position  of  the  pain  is 
not  pathognomonic  of  gastric  ulcer  its  diagnostic 
significance  is  the  result  of  the  position  of  the  organ 
in  the  abdominal  cavity  and  cannot  be  neglected. 
The  great  frequency  with  which  the  smaller  median 
and  right-sided  prepyloric  and  pyloric  portion  of 
the  organ  is  the  seat  of  ulcerative  lesions  causes  the 
pain  to  occupy  a  similar  position  in  a  great  propor- 
tion of  the  cases.  Not  only  is  the  spontaneous  pain 
experienced  in  the  middle  portions  of  the  epigas- 
trium, but  on  testing  the  sensibility  by  percussion 
the  maximum  point  of  tenderness  is  frequently  found 
on  a  line  connecting  the  xiphoid  process  with  the 
umbilicus.  I  must  caution,  however,  against  draw- 


DIGESTIVE  SYSTEM  135 

ing  conclusions  in  regard  to  the  site  of  the  ulcer  from 
this  position  of  the  area  that  is  painful  on  percus- 
sion. It  is  easy  to  convince  oneself,  for  example, 
that  in  cases  of  hepatic  congestion  in  which  the 
hypersensitiveness  of  the  organ  to  mechanical  insult 
is  no  doubt  the  same  throughout,  percussion  is 
always  most  painful  in  the  midline  of  the  epigas- 
trium, while  on  the  right  and  left  sides  it  may  cause 
little  or  no  discomfort.  This  may  be  explained  as 
follows :  On  either  side  of  the  midline  the  recti  blunt 
the  force  of  the  blow  through  their  contraction,  but 
in  the  center,  where,  especially  in  cases  of  ulcer, 
diastasis  of  the  recti  may  exist  together  with  enter- 
optosis,  this  defense  musculaire  is  wanting  and 
the  impact  is  received  unaltered  by  the  stomach. 
This  is  apt  to  be  overdistended  with  gas  and  the  in- 
creased tension  may  result  in  pain  production  quite 
independently  of  the  actual  position  of  the  ulcer.  In 
most  cases  the  lesion  appears  to  be  near  the  pylorus 
on  the  lesser  curvature.  The  tenderness  to  percus- 
sion frequently  begins  about  four  finger  breadths 
below  the  xiphoid  process  and  extends  to  the  neigh- 
borhood of  the  umbilicus.  If  it  begins  immediately 
below  the  xiphoid  and  corresponds  to  an  area  of  dul- 
ness,  the  possibility  of  hyperalgesia  of  the  liver,  per- 
haps through  congestion,  or  following  an  attack  of 
gall-stones,  must  be  seriously  considered.  It  must 
also  be  remembered  that  hepatic  congestion  and  ulcer 
may  occur  coincidently  and  that  the  development 
of  an  ulcer  may  be  favored  by  the  vascular  and  cir- 
culatory disturbances.  Therefore  in  cases  of  myo- 


136  PAIN 

cardial  degeneration,  mitral  stenosis,  etc.,  with  pain- 
ful congestion  of  the  liver  and  accompanied  by  symp- 
toms suggesting  gastric  ulcer,  the  relations  of  the 
tender  area  to  the  liver  edge  should  be  carefully 
studied.  If  it  is  situated  below  this  the  possibility 
of  ulcer  must  always  be  thought  of.  Just  as  spon- 
taneous pain  and  tenderness  to  percussion  or  pres- 
sure may  occur  in  the  midline  anteriorly,  symmet- 
rical backache  or  hyperalgesia  of  one  or  more 
thoracic  or  lumbar  vertebrae  (usually  the  twelfth 
dorsal  or  first  lumbar)  may  sometimes  be  encoun- 
tered. Ulceration  of  the  pylorus  itself  not  rarely 
causes  exquisite  tenderness  on  the  right  side,  which 
may  be  either  just  to  the  right  and  above  the  um- 
bilicus or  nearer  to  the  costal  border  and  therefore 
in  unpleasant  proximity  to  the  gall-bladder.  The 
radiation  of  the  pain  of  pyloric  ulcer  is  less  inti- 
mately associated  with  the  ulcer  as  such  than  with 
the  pyloric  stenosis,  and  will  therefore  be  discussed 
with  the  subject  of  colic  due  to  this  condition.  At 
present  only  the  retrosternal  radiation  sometimes 
observed  in  ulcers  of  the  lesser  curvature  will  be 
mentioned.  Ordinarily  only  the  lower  part  of  the 
sternum  is  involved,  but  sometimes  the  sensation 
extends  upward  toward  the  neck,  and  when  it  is 
accompanied  by  the  sense  of  oppression  and  is  de- 
pendent on  motion  (traction),  confusion  with  angina 
pectoris  may  result. 

The  pain  of  ulcer  is  nocturnal  in  a  considerable 
proportion  of  cases,  the  paroxysms  frequently  occur- 
ring during  the  midnight  hours  (from  11  to  1  o  'clock) 


DIGESTIVE  SYSTEM  137 

and  lasting  into  the  early  morning.  The  relation 
between  the  ingestion  of  .food  and  the  onset  of  pain 
varies  greatly  from  case  to  case,  and  I  should  never 
venture  from  this  to  draw  conclusions  in  regard  to 
the  localization  of  the  ulcerative  process.  Often  the 
pain  begins  immediately  after  eating,  but  sometimes 
it  does  not  occur  until  hours  after  the  last  meal.  In 
pyloric  ulcer,  particularly  if  there  is  also  stenosis, 
there  is  more  regularity  in  this  regard  and  the  pain 
customarily  begins  two  or  three  hours  after  the 
midday  meal,  as  will  be  explained  at  greater  length 
in  discussing  the  subject  of  pyloric  colic. 

THE  NATURE  AND  PATHOGENESIS  OF  THE  PAIN. — 
The  nature  of  the  pain  is  very  variable.  Sometimes 
the  feeling  of  a  "sore  spot"  is  complained  of;  fre- 
quently there  is  simply  a  diffuse  sense  of  pressure 
in  the  epigastrium,  a  sensation  of  heaviness  "as  if 
there  were  a  stone  in  the  stomach. ' '  Sometimes  it  is 
described  as  being  cutting,  piercing,  burning,  or 
gnawing,  or  it  may  be  spasmodic  or  throbbing  in 
character.  The  intensity  of  the  pain,  and  especially 
also  the  tenderness,  may  vary  in  a  short  time  between 
wide  limits  so  that  while  at  one  moment  even  deep 
pressure  may  not  be  painful,  a  few  hours  later  even 
the  contact  of  the  shirt  may  seem  unbearable.  It  is 
evident  that  the  ulcerative  process  itself  undergoes 
no  change  within  so  short  a  lapse  of  time,  but  gastric 
distention  may  develop,  and  I  think  that  this 
accounts  for  the  rapid  fluctuations  so  often  encoun- 
tered. The  more  the  ulcerated  gastric  wall  is 
stretched  by  gas  formation  the  greater  will  be  the 


138  PAIN 

tenderness  to  pressure  and  percussion.  Before  be- 
ginning to  discuss  the  actual  causation  of  the  pain, 
it  may  be  well  to  say  a  few  words  in  regard  to  its 
pathology.  It  is  evident  that  the  conditions  are 
rather  more  complex  than  in  ulcerations  of  the 
buccal  cavity,  for  example,  for  here  we  have  an 
organ  whose  wall  may  sometimes  be  abnormally 
distended  through  the  accumulation  of  gas,  and 
which,  on  the  other  hand,  is  subject  to  spasmodic 
contraction.  Furthermore,  one  must  take  into  ac- 
count its  peritoneal  covering,  which  may  become 
inflamed  over  the  ulcerated  area  (perigastritis),  and 
also  the  production  of  acid  gastric  juice  which  may 
serve  as  a  source  of  irritation.  Every  one  of  these 
factors,  and  of  course  to  a  much  greater  degree 
their  combination,  may  occasion  pain. 

At  this  point  I  should  like  to  touch  briefly  upon 
the  question  as  to  why  the  deep  ulcerations  of  the 
gastric  mucous  membrane  caused  by  carcinoma 
rarely  give  rise  to  painful  seizures  similar  to  those 
of  the  benign  simple  ulcer.  The  acidity  of  the  car- 
cinomatous  stomach  is  also  often  high  owing  to  the 
formation  of  organic  acids,  such  as  lactic,  acetic,  and 
butyric.  In  the  explanation  of  this  apparent  para- 
dox two  factors  play  a  large  part.  (1)  The  carcino- 
matous  stomach  is  much  less  prone  to  spastic  con- 
traction than  is  the  stomach  with  simple  ulcer.  The 
latter  in  spite  of  the  frequently  existing  moderate 
degree  of  motor  insufficiency  is  still  undoubtedly 
in  a  state  of  motor  hyperexcitability  (irritable  weak- 
ness), and  every  spasmodic  contraction  of  the  ulcer- 


DIGESTIVE  SYSTEM  139 

ated  gastric  wall  may  serve  to  cause  pain.  (2)  In 
ulcer  the  stomach  is  more  liable  to  meteorism,  espe- 
cially if  there  coexists  pyloric  stenosis,  either  func- 
tional through  spasm,  or  organic  through  cica- 
tricial  contraction.  The  resulting  tension  of  the  wall 
of  the  organ  is  a  very  active  source  of  pain.  At  any 
raie  the  two-  mechanical  factors  of  contraction  and 
overdistention  play  an  exceedingly  important  part 
in  the  pathogenesis  of  the  pain  of  ulcer. 

Not  rarely  psychical  factors,  such  as  excitement 
or  anger,  are  adduced  by  the  patients  as  initiating  the 
attacks  of  pain.  If  one  takes  into  consideration 
the  interdependence  between  the  emotional  state  and 
the  motor  and  secretory  functions  of  the  stomach, 
and  on  the  other  hand,  the  fact  that  the  intensity 
of  stimulus  necessary  to  evoke  pain  in  an  emotionally 
excited  person  is  reduced,  the  demonstration  of  such 
a  relationship  will  probably  never  be  regarded  as 
by  itself  sufficient  reason  for  assuming  the  existence 
of  a  functional  disorder.  It  is  especially  necessary 
to  be  on  one's  guard  since  gastric  ulcer  is  not  rarely 
associated  with  the  neuropathic  constitution  and  a 
tendency  to  enteroptosis. 

The  mechanical  factors  in  the  process  of  pain 
production  are  of  the  greatest  differential  value  in 
dealing  with  the  pain  of  ulcer  as  opposed  to  that  of 
other  gastralgias,  such  as  those  occurring  in  organic 
or  functional  nervous  disorders  like  tabes  or  neuras- 
thenia, or  those  due  to  secretory  anomalies  or  to 
intoxications  (lead,  nicotine).  It  is  clear  from  what 
has  been  said  above  that  the  way  in  which  mechanical 


140  PAIN 

factors  act  will  not  be  uniform  and  that  the  position 
of  the  ulcer  and  any  existing  adhesions  will  be  of 
importance.  A  peculiarity  frequently  observed  in 
cases  of  ulcer  is  that  during  the  paroxysms,  and 
sometimes  also  at  other  periods,  the  position  of  the 
patient  while  in  the  horizontal  posture,  whether  on 
the  face,  back,  or  side  has  an  undoubted  effect  on  the 
intensity  of  the  pain.  It  may  at  once  be  pointed 
out  that  similar  observations  may  be  made  in  painful 
affections  of  other  organs,  such  as  the  liver,  kidney, 
appendix,  etc.  I  do  not  therefore  agree  with  the 
generally  accepted  explanation  that  in  certain  posi- 
tions the  eroded  surface  is  exposed  to  the  impact,  so 
to  speak,  of  the  gastric  contents,  while  in  others  this 
is  not  the  case.  Assuming  that  the  material  in  the 
stomach  is  pultaceous  and  therefore  not  easily  mov- 
able, as  must  often  be  the  case,  this  explanation 
seems  somewhat  forced.  At  the  most,  it  could  be 
claimed  only  that  the  weight  of  the  overlying 
layer,  which,  however,  cannot  vary  very  greatly, 
may  have  a  pain-increasing  effect,  though  this 
seems  to  me  rather  improbable.  I  should  regard  it 
as  much  more  natural  that,  just  as  in  the  case  of 
other  painful  abdominal  organs,  displacement,  trac- 
tion, or  kinking  at  the  pylorus  takes  place  and  in- 
creases the  pain.  When  the  stomach  is  full  it  is  par- 
ticularly liable  to  displacement  of  this  sort  as  a 
whole  and  in  part,  and  this  can  hardly  be  without 
effect  in  the  presence  of  the  inflammatory  adhesions 
usually  existing.  Such  displacement  in  different 
positions  of  the  body  is  the  more  likely  to  occur  in 


DIGESTIVE  SYSTEM  141 

ulcer  since  not  rarely  the  condition  is  associated 
with  enteroptosis  and  lax  abdominal  walls.  This 
imperfect  fixation  of  the  abdominal  organs  as  a 
whole  is  further  contributed  to  by  the  considerable 
reduction  in  intra-abdominal  padding  due  to  the 
absorption  of  fat  commonly  seen  in  cases  of  ulcer. 
Therefore  I  should  consider  the  effect  of  the  painful 
position  as  due  less  to  a  displacement  of  the  gastric 
contents  than  to  that  of  the  stomach  itself  (cf.  page 
22).  The  patients  themselves  often  complain,  for 
example,  that  when  lying  on  the  left  side  ' '  a  weight 
seems  to  pass  to  the  left. ' '  The  pain  accompanying 
the  lateral  position  is  sometimes  experienced  on  the 
same  side,  but  may  also  be  contralateral,  so  that 
when  lying  on  the  right  side  it  is  felt  to  the  left  of 
the  epigastrium,  and  often  conveys  the  impression 
of  traction  to  the  right.  The  painful  position  may 
be  noted  only  during  the  spontaneous  paroxysms  and 
frequently  appears  to  depend  on  overfilling  of  the 
organ,  which,  of  course,  would  predispose  to  dis- 
placement. It  does  not  seem  to  me  justifiable  to 
draw  conclusions,  as  is  often  done,  in  regard  to  the 
localization  of  the  ulcer  from  the  relations  between 
the  position  of  the  body  and  increase  or  decrease  in 
pain,  since  the  connection  evidently  does  not  depend 
on  simple  displacement  of  the  gastric  contents  due  to 
gravity  alone.  A  fairly  constant  though  not  invari- 
able rule  is  that  painful  lesions  of  the  pylorus,  par- 
ticularly if  accompanied  by  stenosis,  make  the  right 
lateral  position  uncomfortable  during  the  spontane- 
ous attacks  of  pain,  but  more  will  be  said  on  this 
subject  in  discussing  the  pain  of  pyloric  stenosis. 


142  PAIN 

So  far  only  the  horizontal  position  has  been  con- 
sidered. In  walking,  the  body  is  frequently  held  in- 
clined forward,  at  least  at  the  time  of  the  paroxysm. 
Belief  is  sometimes  afforded  in  the  sitting  or  crouch- 
ing position,  but  in  other  cases  these  attitudes  in- 
crease the  patient 's  discomfort.  Movement  of  vari- 
ous sorts  is  also  effective  as  a  mechanical  factor. 
Many  patients  complain  of  an  increase  in  symptoms 
on  walking,  and  it  may  be  assumed  that  the  traction 
and  vibration  to  which  the  stomach  is  subjected, 
particularly  if  the  abdominal  walls  are  relaxed,  is 
responsible  for  the  pain  production.  A  misstep  may 
give  rise  to  severe  momentary  pain  in  the  epigas- 
trium. Exertion  while  stooping,  calling  into  play 
the  abdominal  muscles,  as  in  lifting  heavy  loads,  is 
a  frequent  cause  of  pain,  and  may  bring  on  a  haemor- 
rhage. I  recall  an  instance  in  which  a  patient  after 
lifting  a  heavy  load  experienced  for  the  first  time  a 
burning  sensation  below  the  left  breast,  which  was 
followed  by  the  development  of  typical  ulcer  symp- 
toms. Violent  straining  at  stool  may  act  in  the  same 
way. 

The  respiratory  movements  may  also  cause  pain, 
usually  on  the  left  side  of  the  epigastrium  just  below 
the  costal  border,  particularly  if  perigastritic  com- 
plications are  present.  In  these  cases  the  sensation 
may  radiate  from  the  epigastrium  to  the  left  along 
the  axillary  portions  of  the  thorax  into  the  shoulder. 
It  is  hardly  necessary  to  indicate  that  efforts  such 
as  those  of  coughing  and  sneezing  may  also  be  pain- 
fuL  Under  these  conditions  the  sensation  may  be 


DIGESTIVE   SYSTEM  143 

located  in  the  thorax.  Straining  at  stool  sometimes 
causes  pain  in  the  pyloric  region,  and  in  one  case 
of  mine  about  the  sternal  end  of  the  third  rib.  The 
dependence  of  the  pain  of  ulcer  on  mechanical 
stimuli,  such  as  pressure  and  percussion,  is  among 
its  most  useful  diagnostic  peculiarities,  but  the  im- 
pression appears  to  obtain  that,  as  in  the  case  of  an 
ulcer  in  the  mouth,  the  sensitive  area  corresponds 
to  the  anatomical  lesion  and  depends  on  this  alone. 
Pain  on  pressure  and  on  percussion  are,  however, 
undoubtedly  dependent  on  the  degree  of  tension  of 
the  stomach  wall.  If  the  organ  is  greatly  dilated, 
as  may  occur  without  true  cicatricial  pyloric  stenosis 
through  pyloric  spasm  and  secondary  stagnation, 
pressure  and  percussion  will  be  particularly  painful. 
This  will  be  the  case  over  a  considerable  area,  and 
even  when  the  trauma  does  not  correspond  to  the 
situation  of  the  diseased  spot.  This  view  is  further 
borne  out  by  the  enormous  fluctuations  in  sensitive- 
ness often  occurring  within  a  few  hours  and  running 
parallel  to  the  degree  of  distention  of  the  organ. 
The  possibility  of  determining  the  position  and  size 
of  the  ulcer  by  outlining  the  painful  area  by  percus- 
sion seems  to  me  to  exist  only  when  the  stomach  is 
not  distended.  The  percussion  must  be  very  gentle, 
as  if  forcible  it  acts  as  a  strong  vibration,  such  as 
that  caused  by  coughing,  for  example.  Tenderness  to 
percussion  over  the  epigastrium  should  be  looked  for 
in  the  following  situations:  (1)  From  the  xiphoid 
process  to  the  umbilicus.  (2)  In  the  apex  of  the 
angle  on  each  side  between  the  outer  border  of  the 


144  PAIN 

rectus  and  the  costal  arch.  (3)  At  a  point  about 
2  cm.  to  the  right  of  and  above  the  umbilicus.  (4) 
The  lower  part  of  the  sternum.  In  the  back  hyper- 
algetic  areas  are.  not  rarely  found  in  the  neighbor- 
hood of  the  spinal  column,  particularly  between  the 
shoulder  blades  in  the  neighborhood  of  the  twelfth 
dorsal  vertebra.  The  left  flank  may  also  be  sensitive 
to  percussion  with  the  clenched  fist,  less  rarely  the 
right,  in  contradistinction  to  cholelithiasis.  In  rare 
cases  the  epigastrium,  and  still  more  rarely  the  dor- 
sal regions  just  indicated  are  so  hyperalgetic  that 
simple  contact  and  slight  pressure  (the  weight  of  the 
bed-clothes,  for  example)  are  sufficient  to  cause  pain. 
Overdistention  of  the  stomach  through  diagnostic 
inflation  (caution  is  necessary)  may  give  rise  to 
acute  spontaneous  pain  and  tenderness  to  pressure. 
So  far  we  have  discussed  factors  concerning 
whose  purely  mechanical  nature  there  can  be  no 
doubt.  The  effect  of  diet  presents  a  much  more 
difficult  problem.  Here  one  is  dealing  with  a  com- 
plex of  mechanical,  chemical,  and  thermic  factors, 
and  this  may  explain  the  great  variability  in  the 
effects  of  dietary  regulation,  although  certain  under- 
lying principles  always  stand  out  clearly  from  the 
chaos  of  inconsistencies.  The  mere  fact  that  the 
pain  is  subject  to  alimentary  modification  at  all 
seems  to  me  of  greater  diagnostic  importance  than 
the  exact  manner  and  nature  of  the  effect  produced. 
The  pain-inducing  factor  may  be  regarded  as  purely 
mechanical  when  it  is  the  result  of  the  use  of  foods 
causing  gas  formation.  Here,  as  has  already  been 


DIGESTIVE  SYSTEM  145 

pointed  out  several  times,  it  is  the  gastric  meteorism 
— which  is  predisposed  to  by  the  atony  of  the  ulcer- 
ated stomach  and  its  tendency  to  pyloric  spasm — that 
produces  the  paroxysms  of  pain  through  tension  of 
the  walls  of  the  organ.  This  explains  the  prompt 
relief  that  often  follows  the  evacuation  of  gas  and 
the  beneficial  effect  of  the  local  application  of  an 
ice  bag.  The  act  of  vomiting  sometimes  checks  the 
pain  abruptly.  Some  foods  (e.g.,  pork)  may  have  a 
purely  mechanically  irritating  effect  through  their 
indigestibility  and  act  as  foreign  bodies.  Acid  foods 
and  strong  spices,  including  salt  and  pepper,  are 
nearly  always  badly  borne.  Of  beverages,  hot  tea 
with  milk,  and  milk  to  which  an  alkali  like  lime  water 
or  vichy  water  has  been  added,  seem  to  agree  the 
best.  Coffee,  beer,  wine,  and  cold  water  often  in- 
duce paroxysms  of  pain.  In  exceptional  cases  the 
ingestion  of  coffee  or  whiskey  may  bring  relief  to  the 
pain,  possibly  through  hastening  the  emptying  of 
the  stomach  or  through  an  antifermentative.  action. 
Meat  sometimes  also  has  a  favorable  effect  which  is 
ordinarily  explained  as  due  to  the  neutralization  of 
the  excess  of  hydrochloric  acid.  For  my  part,  as  the 
result  of  numerous  observations,  I  consider  that 
hydrochloric  hyperacidity  is  very  far  from  frequent 
in  ulcer  and  have  furthermore  been  able  to  convince 
myself  that  in  undoubted  cases  of  the  lesion  even 
large  doses  of  dilute  hydrochloric  acid  have  not  in- 
creased the  pain  and  have  sometimes  even  seemed  to 
have  a  favorable  effect,  possibly  through  an  anti- 
fermentative  action.  I  should  always  advise  testing 
10 


146  PAIN 

the  effect  of  acid  and  alkalies  experimentally  in 
cases  of  gastric  ulcer.  If  the  administration  of  alka- 
lies relieves  the  pain  the  proof  of  hyperchlorhydria 
has  not  been  furnished,  for  there  may  exist  what 
I  think  is  rather  frequent,  namely,  a  hypersesthesia 
to  hydrochloric  acid  accompanied  by  even  subnormal 
HC1  values.  In  addition,  the  discharge  of  gas  and 
consequent  reduction  of  gastric  meteorism  sometimes 
produced  must  be  taken  into  consideration.  That 
the  ingestion  of  meat  and  milk  frequently  does  not 
act  exclusively  through  the  neutralization  of  hydro- 
chloric acid  is  shown  by  the  fact  that  not  rarely  a 
piece  of  bread  will  have  the  same-  effect. 

Increased  peristalsis  is  likely  to  attend  the  sen- 
sation of  hunger  caused  by  prolonged  abstinence 
from  food.  This  is  evidenced  under  physiological 
conditions  by  the  " growling  of  the*  stomach,"  and 
the  ingestion  of  food  of  any  sort  appears  to  have  a 
quieting  effect  on  the  spasmodically  increased  motor 
activity.  The  effect  of  tobacco  in  causing  pain, 
which  is  not  only  common  in  essential  gastralgias  but 
also  in  cases  of  ulcer,  may  be  due  in  a  similar  way  to 
the  increased  peristalsis. 

It  is  not  possible  to  formulate  distinct  rules  in 
regard  to  the  effect  of  thermic  stimuli  on.  the  pain 
of  ulcer.  In  most  cases  moderate  warmth,  both  in- 
ternally through  beverages  such  as  warm  milk  or 
tea,  as  also  externally  by  means  of  fomentations  or 
hot  water  bottles,  appears  to  act  favorably  on  the 
pain,  but  cold  (a  swallow  of  cold  water,  or  an  ice  bag 
to  the  epigastrium)  not  infrequently  relieves  in 


DIGESTIVE   SYSTEM  147 

cases  in  which  heat  increases  the  discomfort  of  the 
patient. 

Among  the  interrelationships  between  the  pain  of 
ulcer  and  the  condition  of  other  organs  or  their  func- 
tions, constipation,  which  is  so  frequently  seen  in  this 
disease,  appears  to  me  to  be  of  importance  particu- 
larly from  the  therapeutic  standpoint.  Constipation 
is  undoubtedly  a  pain-producing  factor,  for  when 
it  has  persisted  for  any  length  of  time  the  intensity 
and  frequency  of  the  attacks  nearly  always  increase, 
only  to  subside  again  after  evacuation  of  the  intes- 
tine. Occasional  enemas  of  oil  or  glycerine  and  pos- 
sibly the  regular  administration  of  mild  laxatives, 
such  as  cascara  sagrada,  are  therefore  urgently  indi- 
cated. It  appears  most  likely  that  the  blocking  of 
the  fecal  masses  reacts  upon  the  stomach  and  causes 
stagnation  in  this  organ,  thus  increasing  the  ten- 
dency to  meteorism.  The  effect  of  the  latter  upon 
the  pain  of  ulcer  has  already  been  discussed  at 
length.  It  is  hardly  necessary  to  point  out  that  a 
condition  of  "irritable  weakness"  of  the  nervous 
system  is  unfavorable,  particularly  if  accompanied 
by  anaemia,  and  therapeutic  measures  must  be 
directed  along  these  lines.  No  less  undesirable  is 
the  effect  of  enteroptosis,  which  is  not  infrequently 
encountered  in  neuropathic  individuals.  If  gas- 
troptosis  exists,  the  resulting  kinking  at  the  pylorus 
leads  to  stagnation  and  abnormal  fermentation 
of  the  gastric  content,  while  at  the  same  time  pain- 
ful traction  on  the  organ  is  also  likely  to  be  caused. 
When  pregnancy  has  a  beneficial  effect  on  ulcer 


148  PAIN 

and  its  pain,  as  was  the  ease  in  some  instances  that 
I  recall,  it  is  possible  that  among  other  factors  the 
relief  to  the  condition  of  enteroptosis  produced 
by  the  elevation  of  the  abdominal  viscera  through  the 
enlarging  uterus  is  of  importance. 

ACCOMPANYING  SYMPTOMS. — Among  the  symp- 
toms associated  with  exacerbations  of  pain  the  most 
characteristic  are  those  standing  in  close  relation- 
ship to  the  mechanism  of  pain  production.  For  ex- 
ample, the  distention  of  the  stomach  is  often  evident 
from  the  presence  of  a  rounded  swelling,  or  at  least 
an  air-cushion-like  resistance,  in  the  left  (as  con- 
trasted with  cholelithiasis)  side  of  the  abdomen. 
Pressure  over  this  sometimes  occasions  pyrosis 
through  regurgitation  upward,  sometimes  there  is 
distinct,  easily  produced  succussion.*  Frequently 
there  is  audible  and  palpable  gurgling  owing  to  the 
increased  peristalsis,  or  there  may  be  acid  eructation 
or  belching  of  gas  smelling  like  putrid  eggs  (SH2) 
and  vomiting  followed  by  the  immediate  cessation 
of  the  pain  (as  opposed  to  cholelithiasis).  Chills 
occur  only  rarely  and  then  in  neuropathic  persons 
with  abnormal  vasomotor  excitability;  the  superfi- 
cial abdominal  reflex  is  sometimes  increased  on  the 
left  side,  headache  and  attacks  of  vertigo  are  often 
seen,  as  well  as  the  feeling  of  great  heat  and  sweat- 
ing, especially  during  a  haemorrhage.  Microscopi- 
cally the  examination  of  the  vomitus  or  of  the  feces 


*In  cases  of  gastric  ulcer  it  is  desirable,  in  order  to  avoid  local 
injury  in  testing  for  splashing  in  the  stomach,  to  shake  the  whole 
abdomen  by  grasping  the  two  sides  of  the  pelvis  with  both  hands. 


DIGESTIVE   SYSTEM  149 

may  reveal  the  presence  of  sarcinae,  which  is  a  find- 
ing of  importance.  As  noted  above,  I  do  not  regard 
hyperchlorhydria  as  a  frequent  concomitant  of  ulcer. 
DIFFEBENTIAL  DIAGNOSIS. — If  the  existing  pain 
phenomena  are  analyzed  in  detail  in  this  way,  pay- 
ing special  attention  to  the  causative  factors,  mis- 
takes in  diagnosis  will  be  unlikely.  In  distinguish- 
ing the  paroxysms  of  gastric  ulcer  from  those  of  the 
gastralgias  of  "nervous"  nature,  such  as  may  be 
caused  by  organic  lesions  of  the  nervous  system, 
tabes,  multiple  sclerosis,  syphilis,  etc.,  and  which  are 
often  dependent  on  a  neuropathic  basis,  as  in  hys- 
teria, exophthalmic  goiter  or  nicotinism,  the  inter- 
mittent character  of  the  pain  in  the  latter  may  be 
emphasized.  In  these  conditions,  in  addition  to  the 
sporadic  nature  of  the  attacks  and  the  lack  of  sus- 
ceptibility to  influence  by  mechanical  factors,  such 
as  position,  motion,  or  pressure,  there  is  also  the 
absence  of  permanent  or  consistent  modification 
through  diet.  In  difficult  cases  it  is  advisable  to 
make  careful  dietetic  observations  in  order  to  deter- 
mine the  degree  of  tolerance  for  articles  of  food 
badly  borne  in  ulcer.  The  lack  of  response  to 
dietary  changes  will  also  prevent  confusion  in  cases 
of  epigastric  intercostal  neuralgia.  As  opposed  to 
the  more  occasional  attacks  of  gall-bladder  colic,  the 
pain  of  ulcer  is  characterized  by  greater  persistence 
and  the  action  of  local  anaesthetics  is  of  importance 
(cf.  pyloric  stenosis  colic).  The  existence  of  a 
hernia  of  the  linea  alba,  which  may  exhibit  the  same 
epigastric  tenderness  as  ulcer,  is  easily  recognized 


150  PAIN 

by  palpation  while  the  patient  coughs.  Still,  even 
after  the  discovery  of  a  hernia  the  possibility  of  the 
simultaneous  occurrence  of  both  conditions  must 
be  kept  in  mind.  The  epigastric  tenderness  some- 
times seen  in  chronic  bronchitis  as  a  muscular  phe- 
nomenon involving  the  insertions  of  the  recti  and 
comparable  to  the  pain  in  the  calves  after  fatiguing 
marches,  is  likely  to  lead  to  error  only  if  the  exam- 
ination is  superficial  and  gastric  symptoms  happen 
to  coexist,  as  in  tuberculosis. 

Hepatic  congestion  with  tenderness  seems  to  offer 
a  possibility  of  mistakes  in  diagnosis.  In  cases  of 
ulcer,  associated  with  cardiac  insufficiency  and 
hepatic  congestion — in  which  the  gastric  lesion  may 
be  predisposed  to  by  the  circulatory  disorders — the 
epigastric  pain  is  likely  to  be  ascribed  summarily  to 
the  hepatic  condition,  and  the  stomach  symptoms 
are  explained  in  the  same  way.  It  may  be  that  not 
until  perforative  peritonitis  intervenes,  as  in  a  case 
I  have  seen,  is  the  true  state  of  affairs  recognized. 
It  is  important  to  demonstrate  that  there  is  also  a 
spot  painful  to  percussion  below  the  edge  of  the  liver 
and  that  the  pain  does  not  subside  under  digitalis  as 
is  the  case  in  the  hepatic  condition.  Of  course,  care- 
ful study  of  the  attendant  circumstances  is  also 
necessary.  Angina  pectoris,  especially  in  its  graver 
forms  induced  through  lesions  of  the  aorta  and  coro- 
nary arteries,  may  simulate  the  symptoms  of  ulcer 
if  the  pain  is  localized  in  the  epigastrium  and  evi- 
dence of  gastric  disturbance  like  vomiting  is  present. 
This  is  the  more  likely  to  be  the  case  if  the  epigas- 


DIGESTIVE   SYSTEM  151 

trium  is  tender  to  pressure,  as  the  result  of  inflam- 
matory atheroma  of  the  abdominal  aorta.  In  deal- 
ing with  persons  over  forty,  of  stocky  build  and  pale 
complexion,  with  a  tendency  to  dyspnoea,  thick  arter- 
ies, and  high  blood  pressure,  one  should  always  be 
slow  to  make  the  diagnosis  of  ulcer,  particularly  if 
it  is  found  that  rapid  motion,  stair  climbing,  etc., 
give  rise  to  the  epigastric  pain.  The  characteristic 
anguished  facies  of  the  patients  during  the  attack 
also  gives  a  hint  as  to  the  true  state  of  affairs.  If 
the  dietary  has  no  particular  effect  on  the  pain,  as 
is  usually  the  case,  the  distinction  is  not  difficult  to 
draw.  The  conditions  are  more-  difficult  when  the 
ingestion  of  food  also  induces  attacks  in  coronary 
or  aortic  angina.  In  such  cases  the  nature  of  the 
food  is  frequently  without  significance ;  for  example, 
in  one  case  the  attacks  occurred  no  matter  whether 
the  patient  took  milk  or  pork  and  sauerkraut;  it  was 
the  ingestion  of  food  as  such  irrespective  of  its  qual- 
ity that  caused  the  pain.  Those  cases  should  also 
be  borne  in  mind  in  which  gastric  ulcer  affords  the 
reflex  starting  point  of  hysterical  angina  pectoris, 
particularly  if  aortic  lesions  are  present,  such  as 
aortic  insufficiency.  Neuroses  are  most  apt  to  occur 
in  anatomically  damaged  organs. 

In  all  cases  of  suspected  ulcer  the  region  of  the 
appendix  should  be  examined  for  tenderness.  Just 
as  appendicular  colic  not  rarely  begins  in  the  epigas- 
trium, chronic  appendicitis  may  be  associated  with 
epigastric  symptoms  simulating  ulcer.  The  possible 
combination  of  both  conditions  must  als.o  be  consid- 


152  PAIN 

ered.  In  cases  of  achylia  gastrica,  such  as  occur  in- 
dependently or  as  part  of  the  picture  of  a  pernicious 
ansemia,  ulcer-like  symptoms,  sometimes  even  asso- 
ciated with  the  apparent  symptoms  of  hyperacidity, 
may  occur.  The  demonstration  of  the  absence  of 
hydrochloric  acid  will  give  the  necessary  clue.  The 
same  thing  is  true  of  gastric  carcinoma,  which  some- 
times begins  with  typical  ulcer  symptoms.  In 
chronic  gastritis  tenderness  over  the  pylorus  may 
be  present,  though  this  is  usually  slight.  There  may 
also  be  similar  dietary  symptoms,  though  seizures  of 
severe  pain  are  almost  never  observed.  The  possi- 
bility of  ulceration  in  other  portions  of  the  gastro- 
intestinal canal  must  also  be  taken  into  account. 
These  exhibit  similar  and  therefore  confusing  die- 
tary symptoms.  I  believe  that  it  is  impossible  to 
distinguish  with  any  degree  of  certainty  between  the 
pain  of  gastric  and  of  duodenal  ulcer.  The  appli- 
cation of  the  ansesthesin  test  has  already  been  de- 
scribed (cf.  page  39).  If  the  pain  of  intestinal 
ulceration,  for  example,  of  tuberculous  nature,  is 
accompanied  by  symptoms  such  as  vomiting,  gastric 
splashing,  etc.,  and  is  localized  in  the  epigastrium,  it 
is  very  difficult  to  make  the  distinction,  particularly 
in  view  of  the  similar  behavior  of  the  two  affections 
in  regard  to  the  ingestion  of  food.  The  case-  is  ren- 
dered still  more  complex  if,  as  in  an  instance  ob- 
served by  me,  intestinal  symptoms  such  as  diarrhoea 
and  increased  peristalsis  are  absent.  Under  these 
conditions  the  appearance  of  pain  in  the  lower  abdo- 
men, as  well  as  of  tenderness  in  the  ileocaecal  region, 


DIGESTIVE  SYSTEM  153 

seems  to  me  of  great  importance;  At  any  rate,  great 
caution  is  necessary  in  making  the  diagnosis  in 
patients  having  pulmonary  tuberculosis. 

THE  COLIC  OF  PYLORIC  STENOSIS. 
Just  as  stenosis  of  the  intestine  may  give  rise  to 
attacks  of  colic  more  or  less  independently  of  the 
nature  of  the  obstruction,  paroxysms  of  similar  eti- 
ology are  occasioned  when  the  pylorus  is  narrowed. 
As  is  the  case  in  the  intestinal  canal,  internal  ste- 
noses induced  by  lesions  of  the  mucosa  produce  the 
most  intense  attacks  of  pain.  Fresh  pyloric  ulcera- 
tions  are  not  necessary  for  this ;  it  is  rather  chronic 
cicatricial  inflammatory  changes  or  malignant  new 
growths  that  are  at  fault.  In  short,  the  causes  of  the 
obstruction  may  vary,  but  the  pain  phenomena  in- 
duced are  the  same.  It  therefore  seems  to  me  justi- 
fiable to  classify  separately  the  paroxysms  of  this 
type  and  to  give  them  the  new  designation  of  pyloric 
colic.  In  the  pathogenesis  of  this  it  appears  to  me 
that — as  in  the  stenotic  colics  in  general — the  factor 
of  overdistention  is  of  greater  importance  than  that 
of  muscular  spasm.  The  quality  of  the  pain  itself 
and  particularly  the  accompanying  symptoms  in  ad- 
vanced cases,  such  as  visible  peristalsis,  leave  no 
doubt  in  regard  to  the  underlying  causes.  At  the 
acme  of  the  paroxysm  the  patients  nearly  always 
complain  of  pain  that  is  exquisitely  colicky  and  grip- 
ing in  character  and  is  associated  with  the  sensation 
"as  if  there  were  something  alive  in  the  stomach 
region,"  "as  if  the  stomach  were  contracting  vio- 


154  PAIN 

lently  and  there  were  an  obstruction  to  the  exit  of 
its  contents."  The  spasmodic  attempts  of  the  gas- 
tric muscles  to  force  the  contents  of  the  organ 
through  the  stenosed  pylorus  manifest  themselves 
in  this  way  and  sometimes  even  the  direction  of  peri- 
stalsis from  left  to  right  is  manifest  to  the  sufferer. 
The  distention  that  is  ordinarily  also  present  gives 
rise  to  an  extremely  disagreeable  or  even  painful 
feeling  of  fulness. 

OBJECTIVE  SYMPTOMS. — Although  the  subjective 
sensations  of  the  patient  depending  on  the  underly- 
ing conditions  of  spasm  and  overdistention  give  a 
sufficiently  clear  picture  of  the  actual  condition,  the 
other  objective  symptoms  banish  all  doubt,  at  least 
in  well-marked  cases.  The  cardinal  phenomenon  is 
the  fact  that  the  contours  of  the  stomach  are  ren- 
dered visible  and  palpable.  At  the  same  time  gur- 
gling and  rumbling  sounds  may  be  heard.  This  so- 
called  rigidity  of  the  stomach  is  often  observed  by 
the  patient  himself  as  a  " hardening"  of  the  epigas- 
trium, which  is  likely  to  be  most  marked  on  the  left 
side.  It  corresponds  in  time  fairly  closely  with  the 
paroxysm  of  pain.  The  distended  stomach  does  as  a 
matter  of  fact  become  harder  to  the  touch  and  is 
palpable  as  a  mass  resembling  an  inflated  air-cushion 
in  consistency.  This  is  a  symptom  that  deserves 
consideration  in  all  cases  of  gastric  pain  in  which 
pyloric  stenosis  is  suspected.  If  the  abdominal 
muscles  are  well  developed  and  the  stomach  is  not 
greatly  dilated  the  abnormal  increase  in  peristalsis 
may  not  be  visible,  but  can  be  detected  on  palpation 


DIGESTIVE  SYSTEM  155 

as  a  rapid  change  in  the  degree  of  tension  of  the 
organ.  In  testing  for  this  it  is  advisable  to  palpate 
with  the  outspread  fingers  pressing  vertically  against 
the  abdominal  wall,  especially  over  the  left  half  of 
the  epigastrium  and  below  the  left  costal  border. 
In  some  cases,  particularly  if  there  is  no  gastric  dis- 
tention,  an  increase  in  the  pyloric  resistance  may  be 
felt  at  the  onset  of  the  pain.  The  sausage-like  trans- 
verse mass  so  formed  disappears  again  as  the  pain 
subsides.  If  the  stomach  is  more  dilated  and  ap- 
proaches the  vertical  in  position  peristalsis  is  often 
most  marked  in  the  neighborhood  of  the  umbilicus 
and  little  eminences  appear  at  either  side  of  this. 
More  rarely  the  protuberance  is  in  the  neighborhood 
of  the  gall-bladder.  A  similar  observation  is  some- 
times made  by  patients  with  gall-stones  and  is  due 
to  a  specie  of  erection  of  the  gall-bladder.  The 
auscultatory  manifestations  have  the  same  origin  as 
the  visible  and  palpable  phenomena  and  correspond 
to  the  loud  borborygmi  accompanying  intestinal 
stenosis.  They  are  caused  by  the  gurgling  of  gas 
through  the  narrowed  pylorus  and  are  ordinarily 
followed  by  decrease  of  the  tension  of  the  gastric 
wall  and  subsidence  of  the  paroxysm  of  pain.  The 
evacuation  of  gas  upward  through  the  cardia  has  the 
same  effect.  The  violent  peristalsis  battling  against 
the  pyloric  obstruction  also  often  produces  eructa- 
tions of  sour  material  accompanied  by  retrosternal 
pyrosis  which  may  extend  up  into  the  throat. 
Finally,  there  may  be  vomiting  of  an  abundance  of 
material  that  is  not  bile  stained,  the  act  being  usually 


156  PAIN 

followed  by  cessation  or  considerable  diminution  in 
the  pain,  as  opposed  to  the  vomiting  of  biliary  colic. 
Although  in  the  typical  cases  with  marked  dilatation 
the  large  quantity  of  the  vomitus,  which  comes  up  in 
great  gulps,  and  the  facts  that  the  material  brought 
up  is  almost  never  bile  stained,  frequently  contains 
old  food  particles  and  sarcinae,  and  is  often  hyper- 
acid,  usually  make  the  recognition  of  the  underlying 
conditions  easy,  there  are  other  instances  in  which, 
in  spite  of  years  of  stenosis,  there  is  never  vomiting, 
no  sarcinae  are  to  be  found  in  the  gastric  contents, 
and  there  may  also  be  no  food  residue  in  the  fasting 
stomach.  In  these  cases  there  is  probably  a  compen- 
satory change  without  extreme  stenosis,  and  instead 
of  dilatation  there  is  rather  a  concentric  hypertrophy 
of  the  muscular  layers.  The  absence  of  vomiting 
may  also  be  caused  by  perigastric  adhesions,  and  in 
such  cases  the  careful  study  of  the  attacks  of  colic 
may  be  of  great  diagnostic  importance.  Of  other 
symptoms  frequently  observed  there  may  be  men- 
tioned the  belching  of  gas  having  the  odor  of  putrid 
eggs  (SH2) ;  the  microscopical  pendant  to  this  is  the 
discovery  of  sarcinae.  Another  typical  manifesta- 
tion is  the  presence  of  gastric  splashing,  which  may 
be  elicited  at  any  time,  and  is  often  noticed  by  the 
patient  in  walking.  It  is  only  rarely  (in  neuropathic 
patients  with  an  excitable  vasomotor  system)  that  a 
short  chill  accompanies  the  attack  of  colic.  Eleva- 
tions of  temperature  do  not  go  with  the  seizures  of 
pyloric  stenosis,  as  opposed  to  biliary  colic.  Con- 
stipation is  a  regular  concomitant  in  almost  every 


DIGESTIVE  SYSTEM  157 

case  of  well-marked  pyloric  stenosis  and  is  aggra- 
vated at  the  time  of  the  attack.  The  urine  is  often 
reduced  in  quantity  owing  to  the  loss  of  fluid  through 
vomiting  and  is  darker  in  consequence  of  its 
concentration. 

TIME  OF  ONSET. — The  time  at  which  attacks  of 
pyloric  colic  occur  is  fairly  regular.  In  most  cases 
the  pain  begins  two  to  three  hours  after  the  midday 
meal;  more  rarely  after  the  lapse  of  one  to  four 
hours.  At  this  time  the  expulsion  of  the  gastric  con- 
tents through  the  narrowed  pylorus,  or  an  attempt 
at  this,  takes  place.  Gastric  rigidity  sets  in  and 
gurgling  sounds  are  audible,  while'  gas  is  belched  up 
and  there  are  eructations  of  sour  fluid.  In  short, 
in  typical  cases  there  appear  the  various  manifes- 
tations of  increased  but  ineffectual  peristalsis.  The 
attacks  often  last  from  two  to  three  hours  and  are 
ordinarily  terminated  by  the  onset  of  copious  vomit- 
ing. These  afternoon  attacks  depending  on  the  in- 
gestion  of  the  midday  meal  are  in  many  cases  fol- 
lowed by  nocturnal  seizures  that  are  regular  in 
recurrence  but  do  not  exhibit  a  distinct  connection 
with  the  evening  meal  and  have  a  greater  resem- 
blance to  the  more  isolated  and  sporadic  paroxysms 
of  biliary  colic.  In  some  cases  this  nocturnal  type 
even  predominates.  As  in  colic  of  other  sorts  the 
attacks  are  most  likely  to  occur  at  about  midnight, 
lasting  several  hours  until  copious  vomiting  relieves 
the  tortured  patient  from  his  pain. 

TOPOGRAPHY. — In  regard  to  the  situation  of  the 
pain  I  should  like  to  consider  especially  the  ten- 


158  PAIN 

dency  to  radiation,  which  is  also  prominent,  as  is 
well  known,  in  gall-bladder  colic.  This  appears 
to  depend  in  part  on  the  degree  of  tension  of  the 
stomach  wall.  On  the  evacuation  of  gas  by  belching, 
there-  is  often  abrupt  cessation  of  the  radiating  pain ; 
for  example,  that  passing  into  the  back.  Several 
types  may  be  recognized  from  the  topographical 
standpoint,  but  they  all  have  a  stenosis  of  the  pylorus 
(cicatricial)  as  underlying  cause. 

1.  Type  of  Pseudo- gall-stone  Colic. — The  pain  of 
the  attack  begins  in  the  epigastrium  or  in  the  pyloric 
and  gall-bladder  region,  and  radiates  into  the  right 
lumbar  region  and  right  shoulder.    It  accordingly 
simulates  that  of  biliary  colic,  and  error  is  to  be 
avoided  only  by  a  careful  analysis  of  the  attendant 
circumstances,  time  of  onset,  etc.     The  difficulties 
may  be  still  further  increased  in  those  fortunately 
rare  cases  in  which  pyloric  ulceration — through  in- 
fection, secondary  duodenal  catarrh,  or  adhesions — 
leads  to  lesions  in  the  gall-bladder  or  gall  passages, 
and  therefore  causes  jaundice. 

2.  Type  of  Gall-stone  Colic  tvith  Left-sided  Pain. 
The  pain  begins  on  the  left  side  of  the  epigastrium 
and  radiates  into  the  left  lumbar  region,  left  shoul- 
der, and  possibly  left  breast.     Owing  to  the  left- 
sided  position   of  the   distended   organ   this   type 
appears  to  be  commoner  than  the  preceding. 

3.  Type  of  Pseudo-girdle  Pains. — The  pain  be- 
gins exactly  in  the  middle  line  of  the  epigastrium 
and  extends  in  girdle  form  with  equal  intensity  to 
each  side  to  the  back.     It  may  also  radiate  retro- 
sternally  and  into  both  shoulder  blades. 


DIGESTIVE   SYSTEM  159 

4.  Type  of  Diagonal  Radiation. — The  pain  be- 
gins, for  example,  in  the  right  half  of  the  epigastrium 
in  the  immediate  neighborhood  of  the  gall-bladder, 
but  radiates  backward,  especially  into  the  left  shoul- 
der. Such  left-sided  radiation  is  of  value  in  differ- 
entiating the  condition  from  the  ordinarily  right- 
sided  biliary  colic. 

MODIFYING  FACTORS. — In  this  connection  mechani- 
cal factors  are  of  great  importance,  particularly  in 
regard  to  the  position  of  maximum  pain  (cf.  page 
22).  Lying  on  the  right  side  is  very  likely  to  bring 
on  the  pain  or  to  increase  it  if  already  present.  Dur- 
ing the  intervals  between  attacks  this  position  is 
often  well  borne,  however.  I  have  already  indicated 
my  doubts  in  regard  to  the  assumption  that  the  ex- 
planation is  to  be  found  in  a  simple  settling  or  dis- 
placement of  the  stomach  contents  on  to  the  surface 
of  the  ulcer  or  the  cicatricial  tissues.  This  view  is 
also  opposed  by  the  observation  that  in  some  cases 
of  ulcerative  cicatricial  pyloric  stenosis  the  right 
lateral  position  is  well  borne,  but  the  left  is  accom- 
panied by  nausea,  belching,  etc.,  so  that  the  patients 
turn  on  the  right  side  during  the  attack.  Sometimes 
in  the  course  of  the  disease  a  change  in  the  position 
of  maximum  pain  is  observed  so  that  for  a  time  it 
may  be  the  right  and  later  the  left  side.  It  has  been 
pointed  out  above  that  it  is  therefore  much  more 
rational  to  consider  that  the  effect  of  position  de- 
pends on  kinking,  traction,  inflammatory  adhesions, 
etc.  The  part  played  by  the  overdistention  of  the 
stomach  in  bringing  on  the  attack  is  demonstrated 


160  PAIN 

by  the  fact  that  the  belching  of  gas  and  vomiting 
relieve  or  cut  short  the  paroxysm.  Many  patients 
instinctively  massage  the  distended  epigastrium  or 
they  furnish  a  support  to  the  anterior  stomach  wall 
by  pressure  with  the  fist,  and  in  this  way  favor  the 
evacuation  of  gas. 

It  is  often  possible  to  demonstrate  the  presence 
of  pyloric  tenderness  by  percussion  and  deep  palpa- 
tion. Frequently  it  is  more  or  less  limited  to  a 
point  in  the  linea  alba  between  the  navel  and  the 
xiphoid  process.  Sometimes  there  is  tenderness  of 
the  spinal  column  to  percussion  between  the  shoulder 
blades.  The  influence  of  diet  manifests  itself  in  the 
same  way  as  spoken  of  under  the  heading  of  ulcer. 
It  is  hardly  necessary  to  emphasize  the  fact  that 
owing  to  the  narrowing  of  the  pylorus  the  ingestion 
of  foods  tending  to  produce  distention  or  fermenta- 
tion is  very  likely  to  cause  gastric  meteorism,  and 
that  these  are  particularly  to  be  avoided.  The  fol- 
owing  articles  are  nearly  always  very  badly  borne: 
Potatoes,  turnips,  uncooked  fruit,  cabbage,  smoked 
meat,  and  fatty  foods  in  general,  as  well  as  pastries 
prepared  with  yeast,  and  alcoholic  beverages,  espe- 
cially sour  wines.  Foods  that  agree  well  are  thick 
rice  soup,  spinach,  potato  puree,  tea  with  milk,  milk 
dishes,  chopped  ham,  etc.  The  drinking  of  large 
quantities  of  fluid  is  always  of  untoward  effect. 

In  speaking  of  thermic  stimuli  I  wish  only  to 
point  out  that  in  those  cases  of  pyloric  colic  accom- 
panied by  considerable  distention  of  the  stomach, 


DIGESTIVE   SYSTEM  161 

the  application  of  cold,  possibly  through  its  tonic 
effect  in  encouraging  contraction,  seems  to  be  more 
beneficial  than  the  various  warm  applications  ordi- 
narily used  in  attacks  of  colic.  In  some  such  cases  I 
have  seen  heat  not  only  unproductive  of  relief  but 
the  patients  have  even  complained  of  increase  in 
their  sufferings.  Internally,  lukewarm  drinks  are 
to  be  recommended. 

What  was  said  concerning  the  effect  of  the  func- 
tions of  other  organs  on  the  pain  of  ulcer  is  also  ap- 
plicable here.  The  indication  for  careful  regulation 
of  the  intestinal  functions  is  the  more  important 
since  the  tendency  to  gastric  meteorisin  is  evidently 
more  pronounced  than  in  cases  of  ulcer  not  accom- 
panied by  stenosis.  There  is  no  doubt  in  regard  to 
the  effect  of  constipation  in  increasing  pain.  Psy- 
chical factors,  such  as  overwork  or  excitement,  fre- 
quently cause  the  attacks  to  recur  at  shorter 
intervals.  Disregard  of  this  fact  might  make  con- 
fusion with  functional  conditions  likely. 

DIFFERENTIAL  DIAGNOSIS. — The  possibility  of  mis- 
taking pyloric  colic  for  biliary  colic  is  particularly 
great  in  those  cases  in  which  the  characteristic  evi- 
dences of  pyloric  stenosis,  such  as  gastric  rigidity, 
very  copious  vomiting,  etc.,  are  absent,  or  in  which 
jaundice  appears  as  a  result  of  secondary  duodenal 
catarrh.  Sometimes,  though  fortunately  rarely,  the 
two  conditions  occur  in  combination.  Some  of  the 
more  important  differential  signs  may  be  summar- 
ized in  the  following  table: 
11 


162 


PAIN 


PYLOBIC  COLIC. 

Active  borborygmi  in  the  epi- 
gastrium. 

Distention,  most  marked  below 
the  left  costal  border. 

Acid  eructations  with  heart 
burn;  copious  vomiting  of 
strongly  acid  material  that 
is  not  bile  stained  but  con- 
tains sarcinae  and  possibly 
particles  of  old  food. 

Eructations  smelling  of  SH2. 

Copious  vomiting  or  eructations 
of  gas  are  followed  by  a 
marked  diminution  in  pain. 

Usually  no  chill. 

The  fasting  stomach  contains  old 

food. 
Attacks     are     very     numerous, 

often     occurring     daily     for 

weeks  and  months. 
The  pain  tends  to  radiate  to  the 

left. 
The  attacks  regularly  begin  two 

to    three    hours    after    the 

midday    (or    largest)    meal. 
Foods     causing     gas     formation 

tend  to  increase  the  pain. 
Attacks   of   colic   are   sometimes 

brought  on  by  lying  on  the 

right  side. 

Local  anaesthetics  relieve  the 
pain. 


BILTABY   COLIC. 


Swelling  in  the  gall-bladder 
region. 

Vomiting  of  bitter  material  that 
is  bile  stained  and  is  not 
very  great  in  amount. 


Vomiting  has  no  noteworthy 
effect  on  the  pain  or  it  may 
even  increase  it. 

Often  a  chill  followed  by  eleva- 
tion of  temperature. 


Attacks  are  sporadic,  frequently 
with  intervals  of  several 
months. 

Tends  to  radiate  to  the  right. 

Irregularity  in  time  of  onset,  or 
a  longer  interval  after  eat- 
ing (about  5  hours). 

The  nature  of  the  food  is  of 
comparatively  slight  effect. 

The  left  lateral  position  is  often 
badly  borne  and  is  accom- 
panied by  a  feeling  of  pain- 
ful traction  on  the  right. 

Urine  contains  bilirubin  or  uro- 
bilinogen. 


Numerous  as  the  differential  signs  are,  it  may  in 
some  cases  be  exceedingly  difficult  to  distinguish  be- 
tween these  widely  separated  pathological  condi- 
tions. On  the  one  hand,  there  are  cases  of  very  slight 


DIGESTIVE  SYSTEM  1C3 

pyloric  stenosis  in  which  there  is  good  compensation 
and  the  objective  cardinal  symptoms  are  absent  or 
few,  but  in  which,  possibly  in  consequence  of  gen- 
eral irritability  of  the  nervous  system,  the  attacks 
of  pain  may  be  extremely  severe ;  while  on  the  other 
hand  cholelithiasis  may  be  accompanied  by  symp- 
toms such  as  gastralgia,  or  pain  due  to-'  adhesions 
between  gall-bladder  and  duodenum,  which  arouse 
the  suspicion  of  a  pyloric  stenosis  due  to  ulceration. 
Finally,  of  course,  the  two  conditions  may  coexist. 

Tuberculous  Intestinal  Ulceration. — Ulcerative 
processes  in  the  small  intestine  causing  stenosis 
may  give  rise  to  error,  particularly  if  the  intestinal 
symptoms  are  not  well  marked.  So  in  one  case 
observed  by  the  author  which  came  to  operation,  the 
stools  were  normal,  gastric  symptoms,  comprising 
dilatation  with  persistent  splashing,  vomiting,  etc., 
were  prominent,  the  effect  of  diet  was  as  in  pyloric 
stenosis,  but  the  condition  was  one  of  very  slight 
chronic  intestinal  stenosis  due  to  tuberculous  ulcera- 
tion. In  this  connection  attention  should  be  directed 
to  pain  in  the  lower  abdomen,  which  generally  does 
not  occur  in  pyloric  colic.  On  the  other  hand,  I 
attach  little  diagnostic  value  to  visible  intestinal 
peristalsis  of  slight  degree,  particularly  if  the  ab- 
dominal wall  is  relaxed  and  thin.  I  have  frequently 
seen  this  at  the  acme  of  gastric  peristalsis  in  un- 
doubted cases  of  pyloric  stenosis,  and  regard  it  as 
being  due  to  a  sort  of  sympathetic  activity.  Further 
differential  points  may  be  found  in  the  chapter  on 
gastric  ulcer. 


164  PAIN 

GASTRIC  CANCER. 

In  view  of  the  various  anatomical  lesions  accom- 
panying the  development  of  gastric  carcinoma,  such 
as  pyloric  stenosis,  ulceration,  perigastritis,  meta- 
stases  in  the  liver,  retroperitoneal  glands,  etc.,  as 
well  as  direct  extension  to  neighboring  structures, 
it  might  well  be  expected  that  the  course  of  the  dis- 
ease would  be  accompanied  by  pain.  As  a  matter 
of  fact  this  is  true  in  a  certain  number  of  cases,  and 
the  character  of  the  pain  as  well  as  its  modifying 
factors  often  indicate  the  manner  of  its  causation. 

PAIN  AS  AN  EARLY  SYMPTOM. — While  pain  not 
rarely  begins  very  early,  often  at  a  time  at  which 
anorexia  has  not  yet  set  in  and  the  general  condition 
is  good,  this  is  to  be  explained  by  the  fact  that  in 
most  such  instances  the  growth  has  commenced  very 
near  the  pylorus  and  is  causing  obstruction  at  that 
point.  This  stricture  of  the  pyloric  region,  which 
at  first  is  probably  purely  spasmodic,  manifests  itself 
in  a  series  of  subjective  sensations  which,  according 
to  the  degree  of  stenosis  and  other  circumstances, 
such  as  the  motility  and  total  acidity,  closely  re- 
semble those  described  in  the  section  on  pyloric  colic. 
At  any  rate,  these  subjective  sensations  precede  the 
objective  evidences  of  pyloric  stenosis,  such  as  gas- 
tric rigidity,  by  a  considerable  period  of  time,  and 
this  very  fact  gives  them  a  distinct  importance. 
This  spontaneous  pain  due  to  the  early  onset  of 
pyloric  stenosis  may  be  contrasted  with  other  arti- 
ficially evoked  pains  that  indicate  ulceration  and  are 
the  result  of  the  anatomical  process  (new  growth 


DIGESTIVE   SYSTEM  165 

formation  and  ulceration)  per  se.    We  must  there- 
fore- discuss : 

I.  Pain  due  to  the  local  process,  which  usually 
leads  to  pyloric  stricture. 

II.  Pain  caused  by  the  local  invasion  of  other 
organs,  or  distant  metastases. 

III.  Pain  resulting  from  inflammatory  complica- 
tions,   such    as    perigastritis    and  local  or  diffuse 
carcinomatous  peritonitis. 

I.  A  priori  it  might  be  expected  that  the  phe- 
nomena comprised  under  this  heading  would  be  iden- 
tical with  those  described  in  the  section  on  pyloric 
stenosis  which  was  devoted  to  the  benign  cicatricial 
stenosis.  One  would  suppose  that  the  malignancy 
of  the  ulcerative  process  would  not  alter  the  char- 
acter of  the  pain.  In  fact,  there  are  cases  of  gastric 
carcinoma  which  during  their  entire  course  are  ac- 
companied by  just  such  painful  phenomena,  pecu- 
liarities of  radiation,  etc.,  as  were  described  in  the 
chapter  referred  to.  In  general,  however,  the  inten- 
sity of  the  spontaneous  attacks  is  less  and  the 
progress  of  the  stenosis  and  increased  activity  of 
peristalsis  are  often  accompanied  by  a  marked  de- 
crease in  the  pain,  so  that  it  may  be  said  that  be- 
nign pyloric  stenosis  is  much  more  painful  than  the 
malignant  form.  The  rather  paradoxical-appearing 
fact  that  the  malignant  stenosis  is  exceeded  in  pain 
by  the  benign  process  is  readily  explained  on  more 
careful  consideration.  The  mere  decrease  in  appe- 
tite accompanying  carcinoma  causes  dietary  errors 
— which  are  so  often  responsible  for  attacks  of  colic 


166  PAIN 

in  benign  stenosis — to  be  much  rarer.  In  addition 
the  musculature  of  the  carcinomatous  stomach  early 
becomes  atonic,  whereas  in  ulcer  it  is  more  likely 
to  be  hypertonic,  or  at  least  in  a  condition  of  irritable 
weakness,  which  renders  it  easily  excitable  and  prone 
to  spasm.  At  the  very  beginning  of  the  affection 
the  pain  in  carcinoma  may  present  great  similarity 
to  that  of  ulcer.  While  the  appetite  is  still  good,  the 
dietary  is  not  appropriately  restricted,  and  therefore 
the  early  stages  of  a  carcinoma  are  sometimes  accom- 
panied by  very  intense  pain.  One  of  the  most  fre- 
quent initial  symptoms  of  cancer  of  the  stomach  is 
a  sensation  of  pressure  in  the  epigastrium,  usually 
occurring  about  half  an  hour  after  eating.  Some- 
times this  is  simply  a  disagreeable,  uncomfortable 
feeling,  but  in  others  it  already  has  the  quality  of 
pain.  The  patients  often  speak  of  "a  heaviness  in 
the  stomach."  This  sensation  of  fulness,  tension,  or 
pressure  in  the  epigastrium,  sometimes  accompanied 
by  " burning,"  appears  to  correspond  to  the  first 
degree  of  commencing  narrowing  of  the  pylorus,  and 
may  be  the  result  of  a  functional  spasmodic  stenosis, 
for  at  this  time  other  objective  symptoms  of  perma- 
nent organic  stricture  are  usually  absent.  Some- 
times it  is  possible  at  the  moment  of  appearance  of 
this  sensation,  which  frequentty  lasts  for  only  a 
short  time,  to  detect  a  momentary  air-cushion  resist- 
ance in  the  epigastrium  due  to  a  wave  of  contraction 
of  the  organ.  If  the  stenosis  increases,  stronger 
contractions  striving  to  overcome  the  obstruction 
appear,  and  these  are  manifested  to  the  patient  as 


DIGESTIVE  SYSTEM  167 

pains  of  a  knife-like  boring  and  twisting  character. 
Sometimes  the  sensation  is  described  "as  if  a  ball 
were  rolling  around."  These  are  true  colic  pains 
and  the  spasmodic  contraction  in  the  epigastrium 
may  become  exceedingly  violent;  in  such  cases  it  is 
usually  followed  by  vomiting. 

ACCOMPANYING  SYMPTOMS.  —  These  variously 
graduated  sensations,  ranging  from  a  simple  feeling 
of  pressure  to  colicky  pain,  may  be  accompanied 
by  other  manifestations  also  differing  in  intensity. 
The  slight  initial  grades  of  stagnation  and  the  sub- 
jective sensation  of  simple  pressure,  which  often  is 
not  really  painful,  may  be  accompanied  by  eruc- 
tation of  small  quantities  of  acid  fluid,  frequently 
accompanied  by  heartburn,  or  there  may  be  belch- 
ing of  odorless  gas;  while  in  benign  stenoses  the 
gas  has  the  odor  of  putrid  eggs  (SH2).  Copious 
vomiting,  or  indeed  vomiting  at  all,  does  not  usually 
occur  during  this  initial  stage  of  epigastric  pressure 
after  eating.  It  has  already  been  pointed  out  that 
not  infrequently  advanced  malignant  stenoses  ex- 
hibit a  contrast  between  the  intensity  of  the  stenosis 
and  the  slightness  of  the  pain,  and  an  explanation 
for  this  has  been  offered.  If  a  benign  stenosis  be- 
comes malignant  an  apparent  improvement  may  re- 
sult, as  the  attacks  of  pain  sometimes  become  less  or 
cease  entirely.  It  may  also  be  mentioned  that  in 
malignant  stenosis  bile-stained,  yellow-colored  vomi- 
tus  is  more  frequent  than  in  cases  of  benign  stricture, 
owing  to  the  absence  of  marked  pyloric  spasm  in  the 
former  condition. 


168  PAIN 

The  vomiting  of  a  coffee-ground  character,  which 
occasionally  accompanies  the  benign  stenoses,  has 
been  mentioned  above.  In  the  stage  of  simple  epi- 
gastric pressure,  anorexia  is  not  usually  present. 
On  the  other  hand,  there  is  a  certain  amount  of  intol- 
erance for  meat  and  solid  food,  especially  cooked 
food,  and,  even  earlier,  intolerance  for  vegetables 
and  for  beer.  Sluggishness  of  the  bowels  deserves  to 
be  mentioned  as  a  symptom  which  is  occasionally 
very  early  in  its  occurrence  and  is  rarely  absent  in 
the  later  stages. 

Chemical  and  microscopical  examinations  of  the 
stomach  contents  are  rarely  decisive  during  this 
initial  stage  of  subjective  symptoms.  It  is  always 
well  to  note  the  presence  of  slight  bulging  of  the 
epigastrium,  especially  in  its  left  half,  which  repre- 
sents a  rudimentary  peristalsis  and  is  present  espe- 
cially after  the  taking  of  food.  This  symptom,  of 
course,  as  well  as  the  rigidity  of  the  epigastrium 
which  comes  a  little  later,  depends  more  or  less  upon 
the  development  and  natural  stiffness  of  the  abdom- 
inal muscles. 

Occasionally  the  colicky  pains  occur  two  or  three 
hours  after  meals.  In  other  cases  they  show  a  de- 
cidedly nocturnal  type  (eleven  o'clock  at  night,  last- 
ing until  about  two  A.M.).  Frequently,  however, 
they  follow  directly  upon  the  taking  of  food.  The 
feeling  of  heaviness,  especially,  occurs  either  imme- 
diately upon,  or  within  a  half  hour  after,  the  taking 
of  food.  Only  in  very  rare  cases  are  these  pains 
postponed  for  a  longer  interval  than  six  to  seven 
hours  after  a  large  meal. 


DIGESTIVE   SYSTEM  169 

In  regard  to  the  abdominal  regions  involved,  a 
great  similarity  with  the  previous  conditions  may  be 
observed.  In  many  cases,  for  instance,  there  is  a 
definite  relation  between  the  posture  of  the  patient 
and  the  pain.  When  the  patient  lies  on  the  right 
side,  there  is  commonly  an  increase  of  pain,  abdom- 
inal bulging,  and  nausea.  Here,  as  in  the  case  of  the 
pain  accompanying  pyloric  stenosis,  the  suffering  is 
immediately  ameliorated  by  the  belching  of  gas  and 
by  vomiting.  In  every  respect  where  the  mechanical 
agencies  are  involved  the  analogy  of  this  condition 
with  pyloric  stenosis  is  so  close  that  the  subject  can 
be  dismissed  by  referring  to  the  chapter  on  pyloric 
stenosis. 

There  is  a  marked  similarity  also  in  regard  to  the 
influence  of  diet  upon  the  pain.  The  sensations  of 
pressure  and  of  hunger  which  so  frequently  occur 
in  neuroses  of  the  stomach,  in  which  the  pain  is 
alleviated  by  the  taking  of  food,  occur  but  rarely  in 
this  condition.  It  is  an  almost  invariable  rule  that 
food  increases  or  begins  the  pain,  and  in  this  respect 
the  quality  of  the  food  plays  a  very  important  role, 
the  most  troublesome  articles  of  food  being  boiled 
beef,  heavy  vegetables,  rye  bread,  and  fluids  of  all 
kinds,  especially  beer  and  acid  wines. 

We  have  still  to  consider  th'e  localization  of  the 
pain,  and  in  this  connection  we  must  differentiate 
between 

(a)  Subjective  pains,  and 

(b)  Objective  pains  produced  by  pressure  and 
percussion. 


170  PAIN 

(a)  Subjective  Pains. — The  pain  is  usually  pro- 
jected forward  into  the  epigastrium.  More  rarely 
it  is  situated  retrosternally  under  the  lower  half  of 
the  sternum.  In  the  epigastrium  there  may  be  vari- 
ations in  the  position  of  the  pain  just  as  in  gastric 
ulcer.  In  some  cases  the  left  side  of  the  epigastrium 
becomes  the  most  painful  area;  in  other  cases  the 
mid-line  is  the  seat  of  greatest  pain;  and,  again, 
in  other  cases,  the  suffering  is  chiefly  localized  over 
the  pyloric  region.  The  subjective  pain  may  remain 
localized  here,  or,  just  as  in  benign  stenoses,  it  may 
radiate  especially  into  the  loins  and  back,  toward 
the  hypochondriac  regions,  and  occasionally  even 
into  the  shoulder  blades.  The  pain  which  occa- 
sionally is  noticed  as  radiating  up  behind  the  ster- 
num into  the  throat  is  usually  accompanied  by  re- 
gurgitations  of  the  acid  stomach  contents,  and  may 
easily  be  controlled  by  small  doses  of  alkalies. 
Those  pains  in  the  back  which  are  produced  by  a 
pyloric  stenosis  and  secondary  dilatation  of  the 
stomach  as  such,  and  not  by  metastases,  are  in 
direct  proportion  to  the  epigastric  pains,  are  in- 
creased and  decreased  with  these,  and  are  simply 
backward  radiations  of  these  pains.  Their  appear- 
ance seems  to  be  favored  by  constipation  and  they 
disappear  with  thorough  emptying  of  the  bowels. 
Such  pains  may  occasionally  be  produced  when  the 
stomach  is  artificially  inflated,  a  fact  which  may  be 
regarded  as  important  in  clearing  up  the  mechanism 
of  such  sensations. 


DIGESTIVE  SYSTEM  171 

(b)  Objective  Pains. — Not  infrequently  it  is  pos- 
sible to  map  out  by  palpation,  and  occasionally  even 
by  percussion,  a  definite  hyperaesthetic  zone  in  the 
epigastrium,  which  frequently  corresponds  to  the 
position  of  the  tumor.  In  those  cases  where  a  tumor 
is  impalpable  on  account  of  its  small  size  or  of  great 
muscular  development  of  the  epigastrium,  the  local- 
ization of  such  a  hyperaesthetic  area  may,  if  cau- 
tiously interpreted,  give  much  diagnostic  aid.  If 
such  a  zone  be  placed  asymmetrically  on  the  left  or 
right  side  below  the  costal  border,  it  will  be  more 
worthy  of  notice  than  if  placed  mesially. 

As  in  gastric  ulcer,  the  vertebral  column  in  its 
interscapular  and  dorsolumbar  regions,  as  well  as 
in  the  left  lumbar  region,  is  frequently  painful  to 
percussion. 

II.  Following  the  classification  proposed  above, 
we  are  now  about  to  deal  with  those  painful  sensa- 
tions which  depend  upon  local  extension  of  the  proc- 
ess as  well  as  upon  metastases  into  other  regions. 
These  are,  of  course,  of  much  less  importance,  since 
we  are  no  longer  dealing  with  early  symptoms ;  on 
the  other  hand,  they  will  find  further  mention  when 
we  reach  the  discussion  of  organic  pains  of  other 
regions  (hepatalgia,  etc.). 

These  pains,  in  contradistinction  to  those  dealt 
with  above,  are  differentiated  in  general  by  their  per- 
sistence and  by  their  independence  from  digestive 
influences,  so  that  even  when  localized  in  the  epigas- 
trium (metastases  into  the  liver,  pancreas,  and 
glands),  they  are  easily  separated  from  the  pains 
previously  described. 


172  PAIN 

III.  Tnfla.TnTna.tory  complications  are  often  the 
basis  for  the  pains  occurring  with  gastric  carcinoma ; 
these  may  be  more  or  less  local,  as  in  fibrinous  or 
purulent  perigastritis,  or  diffuse,  as  in  carcino- 
matous  peritonitis. 

The  new  growth  itself  does  not  seem  to  be  par- 
ticularly sensitive  to  pressure.  In  cases  where  a 
more  severe  sensitiveness  to  pressure  exists,  we  are 
usually  dealing  with  a  superimposed  inflammatory 
process  in  the  ulcerated  tumor  mass.  A  localized 
peritonitis  may  occasionally  be  evidenced  by  a 
noticeable  leather-like  creaking  brought  out  by  pal- 
pation. The  motion  of  the  tumor  mass  in  such  cases 
produces  pain  by  rubbing  against  the  inflamed  por- 
tions of  the  peritoneum.  This  may  be  brought  about 
by  coughing,  bending  forward,  pressure  during  defe- 
cation, deep  breathing,  etc. 

Eapid  changes  of  position  also  (from  the  dorsal 
position  to  the  right  or  left)  may  in  the  same  way, 
by  producing  sudden  motion  of  the  tumor,  give  rise 
to  local  pain.  Whenever  the  perigastric  process 
extends,  giving  rise  to  subphrenic  abscesses  or  to 
pleurisy,  which  seems  to  occur  usually  on  the  left 
side,  pain  will  occur,  on  this  side  in  the  lower  inter- 
costal spaces,  in  addition  to  the  epigastric  pain. 

But  in  cases  where  the  peritoneum,  as  a  whole, 
is  involved  in  the  carcinomatous  process  inflamma- 
tory changes  usually  take  place  and  give  rise  subjec- 
tively to  general  abdominal  tenderness,  and  to  a 
painful  sensation  of  general  distention. 


DIGESTIVE   SYSTEM  173 

The  pain  which  depends  upon  peritoneal  involve- 
ment may  frequently  be  influenced  by  local  treatment 
(sapo  kalinus,  tincture  of  iodine,  alcoholic  com- 
presses, etc.) ;  on  the  other  hand,  lavage,  which  fre- 
quently relieves  pains  due  to  stagnation  in  the 
stomach  and  overdistention  of  its  walls,  increases 
the  pain  when  we  are  dealing  with  a  perigastric  con- 
dition, in  that  it  is  contrary  to  the  first  principle 
of  treatment  in  inflammatory  processes,  i.e.,  immo- 
bilization. 

It  is  only  after  a  careful  consideration  of  all  the 
elements  involved,  and  a  careful  physical  examina- 
tion, that  we  can  reach  the  conclusion  that  certain 
pains  are  due  to  the  development  of  a  gastric  carci- 
noma. Of  the  most  practical  importance  are  the 
epigastric  sensations  which  have  been  described  un- 
der I.,  and  which  appear  at  a  time  when  other  symp- 
toms, such  as  anorexia,  progressive  emaciation, 
achlorhydria,  etc.,  are  still  absent,  and  the  patient 
is  as  yet  unaware  of  any  severe  illness. 

In  this  connection  all  those  conditions  which  have 
been  mentioned  under  gastric  ulcer  and  pyloric 
stenosis  must  again  be  considered  in  making  the 
differential  diagnosis.  The  greatest  difficulty  will 
be  encountered  in  the  exclusion  of  gastric  ulcer,  both 
in  its  development  and  in  its  recurrence.  Suspicions 
of  carcinoma  will  be  strengthened  when  the  general 
symptoms  of  gastric  ulcer  and  anorexia  persist,  in 
spite  of  rest  in  bed  and  regulation  of  the  diet.  Diffi- 
culty may  occasionally  be  experienced  in  separating 
carcinoma  of  the  stomach  from  the  dyspepsia  which 


174  PAIN 

accompanies  cases  of  chronic  tuberculosis.  This 
may  occur  with  but  slight  involvement  of  the  lungs 
and  may  give  rise  to  such  extreme  anorexia  and 
progressive  emaciation  that  the  suspicion  of  early 
carcinoma  is  aroused.  These  cases,  however,  are 
rarely  accompanied  by  the  attacks  of  spontaneous 
epigastric  pains  which  characterize  gastric  carci- 
noma. Even  in  tuberculosis  it  is  not  rare  to  find 
epigastric  tenderness,  and  this  is  easily  explained 
by  oversensitiveness  at  the  points  of  insertion  of  the 
rectus  muscle,  produced  by  severe  paroxysms  of 
coughing. 

INTESTINAL  ULCERATION. 

Ulcerations  of  the  gut  give  rise  to  more  or  less 
characteristic  phenomena  of  pain,  though  they  do 
this  less  regularly  than  do  ulcerations  of  the 
stomach.  Tuberculous  ulcerations  are  the  most  fre- 
quent, and  they  may  be  taken  as  an  example  of 
intense  intestinal  ulcerative  and  obstructive  condi- 
tions throughout.  Tuberculous  ulcerations,  how- 
ever, give  rise  to  attacks  of  pain  more  characteristic 
than  those  arising  from  other  intestinal  ulcers  (for 
instance,  those  of  typhoid  and  dysentery).  The  ex- 
planation for  this  may  be  easily  found  in  the  fact 
that  they  have  a  greater  tendency  to  produce  ste- 
nosis, and  that  during  their  existence  the  pain  is 
less  definitely  under  dietetic  control  than  is  gener- 
ally the  case  in  typhoid  and  dysentery. 

Similarly  to  gastric  ulcers,  the  tuberculous  ulcera- 
tions of  the  gut  may  remain  entirely  latent.  This, 


DIGESTIVE   SYSTEM  175 

however,  is  not  frequently  the  case.  The  production 
of  stenosis  is  here,  as  in  conditions  of  the  stomach, 
one  of  the  chief  causes  of  pain;  added  to  this,  of 
course,  are  the  conditions  of  enteritis,  abnormal  fer- 
mentation, and  the  peritoneal  lesions  produced  by 
perienteritis. 

The  pain  accompanying  stenoses  is  closely  analo- 
gous to  the  colic  resulting  from  pyloric  stenosis. 
Even  the  localization  of  the  pain  is  occasionally  very 
similar,  so  that  the  patient  when  consulting  the 
physician  describes  it  as  epigastric.  Spontaneous 
pains  frequently  begin  in  the  epigastrium.  Badia- 
tion,  in  these  cases,  towards  the  ileocaecal  region  is 
of  considerable  importance,  since  such  radiation  is 
very  uncommon  in  gastric  conditions.  This  may  be 
due  to  the  anatomical  position  of  the  lesion,  since 
the  ileocaecal  region  is  involved  with  special 
frequency. 

Pain  is  noticed  in  the  umbilical  region  rather 
more  frequently  than  in  the  epigastric ;  here  it  may 
occur  to  the  right  or  left  of  the  mid-line,  and  may 
extend  to  both  sides,  encircling  the  body.  The  most 
common  seat  of  the  pain,  however,  is  the  hypogastric 
region,  and  here  it  occurs  especially  in  the  right  side. 
The  pain  is  usually  projected  forward ;  it  rarely 
is  localized  in  the  back ;  but  when  it  is,  the  posterior 
pain  is  always  accompanied  by  the  anterior  pain, 
and  is  directly  dependent  upon  the  taking  of  food. 

The  objective  pains  produced  by  pressure  or  per- 
cussion generally  correspond,  in  localization,  with 
the  subjective  ones;  therefore  the  ileocaecal  region 


176  PAIN 

is  almost  always  sensitive.  This  is  likewise  true 
of  the  hypogastrium,  especially  when  there  is  dis- 
tention.  There  is  frequently  a  well-localized  pain- 
ful zone  in  the  neighborhood  of  the  umbilicus  which, 
especially  if  situated  above  the  umbilicus,  gives  rise 
to  a  suspicion  of  gastric  ulcer.  In  such  cases  it  is 
important  to  determine  whether  or  not  this  area  of 
pain  is  situated  above  or  below  the  major  curvature 
of  the  stomach. 

The  time  of  occurrence  of  the  pain  is,  in  many 
cases,  in  direct  relation  to  the  taking  of  food.  This 
is  especially  noticeable  in  connection  with  the  large 
meal  in  the  middle  of  the  day,  which  is  followed, 
with  more  or  less  regularity,  within  one  half  to  one 
hour,  by  attacks  of  pain  which  may  last  for  several 
hours.  While  the  length  of  this  interval  between 
the  meal  and  the  onset  of  pain  varies  greatly  in  dif- 
ferent individuals,  there  is  great  constancy  in  the 
duration  of  the  interval  in  the  same  individual,  in 
that  attacks  occur  in  one  case  with  great  regularity 
in  from  three  to  four  hours,  in  other  cases  in  from  six 
to  seven  hours  after  meals.  Whenever  a  very  short 
time  elapses  between  the  meals  and  the  appearance  of 
the  pain,  we  are  undoubtedly  dealing  with  a  stimula- 
tion of  intestinal  peristalsis  produced  by  the  food 
still  remaining  in  the  stomach;  and  it  is  this  peri- 
stalsis which  produces  the  pains  in  the  ulcerated 
area.  It  is  important  to  note  that  patients  with  this 
form  of  intestinal  ulceration  may  experience  entire 
freedom  from  pain  during  intervals  often  lasting 
for  months.  As  the  disease  progresses,  these  free  in- 


DIGESTIVE  SYSTEM  177 

tervals  become  shorter  and  shorter,  until  the  attacks 
are  of  daily  occurrence ;  this  is  due,  of  course,  to  the 
constantly  increasing  stenosis. 

Mechanical  Considerations. — Since  the  condition 
is  most  frequently  localized  in  the  ileocascal  region, 
the  pain  is  usually  most  severe  in  this  region.  Thus 
the  patients,  when  lying  on  the  left  side,  complain  of 
feeling  as  though  something  were  being  drawn  from 
the  ileocsecal  region  into  the  left  side,  while  when 
lying  on  the  right  side  the  pain  is  directly  localized 
in  this  region.  In  general,  the  position  on  the  left 
side  is  less  painful  than  that  on  the  right.  This  is 
undoubtedly  due  to  the  traction  brought  about  by 
the  weight  of  the  diseased  gut  and  of  the  involved 
glands,  a  traction  which  is  the  more  painful  because 
peritoneal  inflammations  and  adhesions  are  com- 
paratively frequent. 

The  condition  may  be  confused  with  cases  of 
acute  and  chronic  appendicitis  where  the  same  pecu- 
liarities as  to  the  relation  of  pain  and  position  are 
present.  This  error  is  more  easily  made  because 
in  both  of  these  conditions  the  patient  will  be  re- 
lieved by  flexion  of  the  right  leg  at  the  hip  through 
relaxation  of  the  abdominal  muscles  during  the 
attacks. 

The  pain  which  is  elicited  in  circumscribed  areas, 
especially  the  hypogastric  and  umbilical  regions,  by 
jarring  of  the  body,  as  in  coughing,  walking  down- 
stairs, rapid  turning  and  deep  inspiration,  is  easily 
explained  by  the  correspondingly  localized  inflam- 
matory processes  in  the  peritoneum, 
12 


178  PAIN 

A  number  of  other  minor  symptoms  unquestion- 
ably depend  upon  the  fact  that  the  intestinal  pain 
is  frequently  accompanied  by  local  or  general  dis- 
tention.  Thus  the  patients,  during  their  attacks, 
rub  the  hypogastrium,  place  their  hands  upon  their 
hips  and  turn  the  trunk  upon  the  pelvis  in  an  in- 
stinctive attempt  to  cause  a  general  distribution  of 
the  local  distention.  The  same  fact  explains  the 
relief  produced  by  enemata,  by  vomiting,  or  by  the 
discharge  of  gas  per  os  or  per  anum,  all  of  which 
bring  about  a  relief  of  the  distended  intestinal  wall. 

The  influence  of  the  diet  upon  the  pain  is  depen- 
dent upon  this  very  question  of  distention;  and  the 
same  conditions  which  we  considered  in  speaking  of 
gastric  ulcer  and  of  pyloric  stenosis  must  be  taken 
into  account  here.  In  the  first  place,  those  articles 
of  diet  which  give  rise  to  fermentation  will  cause 
pain.  Chief  among  these  are  cabbage,  turnips,  len- 
tils, potatoes,  pastries  prepared  with  yeast,  rye 
bread,  beer,  not  infrequently  milk,  and  furthermore 
all  those  articles  of  diet  which  are  apt  to  constipate. 

Great  pain  can  be  produced  by  those  articles  of 
diet  which  produce  active  peristalsis  when  present 
in  the  stomach;  this  probably  explains  the  attacks 
of  pain  which  regularly  occur  a  few  minutes  after 
the  ingestion  of  ccld  beverages  (water,  milk),  strong 
coffee,  and  certain  drugs,  as  thiocol;  on  the  other 
hand,  these  very  articles  which  stimulate  peristalsis 
may  aid  in  relieving  local  distention  and  thus  have 
the  opposite  effect.  Direct  chemical  irritation  of 
the  ulcerated  areas  probably  occurs  very  rarely; 


DIGESTIVE  SYSTEM  179 

but  if  it  does  occur  this  may  explain  the  production 
of  pain  by  very  acid  food  such  as  salad.  More  fre- 
quently mechanical  injury  may  be  caused  by  the 
ingestion  of  solid  food,  especially  raw  fruit ;  so  that 
in  general  a  fluid  or  semi-solid  diet  is  to  be  preferred. 

It  is  self-evident  that  the  quantity  of  food  intro- 
duced may,  by  its  filling  of  the  intestine,  become  a 
serious  consideration  in  the  production  of  pain. 

Just  as  the  introduction  of  cold  substances  may 
produce  pain  by  their  active  stimulation  of  peri- 
stalsis, so  also  thermic  influences  brought  to  bear 
from  without  may  play  a  similar  role. 

Chilling  of  the  feet  seems  to  have  special  in- 
fluence in  initiating  attacks  of  pain.  Thus  attacks 
may  be  brought  on  by  walking  upon  a  cold  floor  with 
bare  feet.  This  is,  in  general,  a  peculiarity  of  pains 
due  to  intestinal  peristalsis  and  may  have  a  certain 
amount  of  differential  value.  Applications  of  cold 
compresses  to  the  abdomen,  in  that  they  relieve  dis- 
tention,  usually  have  a  favorable  influence;  while 
the  application  of  heat  often  increases  the  pain. 

The  secondary  symptoms  are  especially  impor- 
tant because  they  so  frequently  give  rise  to  errors 
in  diagnosis. 

The  importance  of  this  fact  is  well  illustrated  by 
those  cases  of  tuberculous  ulceration  which  are 
accompanied  by  gastric  symptoms,  vomiting  and 
belching.  The  vomiting  is  often  in  large  quantities, 
and  in  the  vomitus  there  are  frequently  particles 
of  food  which  have  been  ingested  several  days  be- 
fore. In  these  cases  we  are  unquestionably  dealing 


180  PAIN 

with  stagnation  in  the  stomach,  secondary  to  the  ob- 
struction in  the  gut.  The  very  facts  that  the  vomit- 
ing is  copious,  that  the  microscopical  examination 
points  to  stagnation,  and  that  the  clinical  signs 
obtained  on  palpation  indicate  moderate  dilatation, 
may  give  rise  to  the  erroneous  diagnosis  of  pyloric 
stenosis.  This  error  may  be  more  easily  made  since 
the  pain  in  these  cases  is  often  localized  in  the  epi- 
gastrium, and  occasionally  there  may  be  an  entire 
absence  of  symptoms  referable  to  the  intestines, 
such  as  diarrhoea,  or  even  irregularity  of  the  bowels. 
We  have  already  pointed  out  the  great  similarity 
which  may  exist  between  the  two  conditions  in  re- 
gard to  the  influence  exerted  upon  the  pains  by  the 
diet. 

In  doubtful  cases  it  is  particularly  important  to 
remember  that,  in  contrast  with  pyloric  stenosis, 
the  vomitus  frequently  contains  bile,  and  the  pains 
are  radiated  either  into  the  hypogastrium,  or,  more 
frequently,  into  the  ileocsecal  region.  The  discovery 
of  sarcinae  in  the  vomitus  is  pretty  positive  indica- 
tion of  the  gastric  nature  of  the  condition. 

Diarrhoea,  especially  the  very  foul  variety  which 
occasionally  accompanies  tuberculous  ulcerations,  is 
almost  unknown  in  cases  of  pyloric  stenosis.  These 
are  almost  invariably  accompanied  by  constipation.. 
For  this  reason,  too,  the  succussion  noticed  occasion- 
ally in  cases  of  tuberculous  ulceration  is  extremely 
rare  in  pyloric  stenosis.  Withal  it  must  not  be  for- 
gotten that  both  conditions  may  occasionally  be  pres- 
ent at  the  same  time. 


DIGESTIVE   SYSTEM  181 

It  is  sometimes  extremely  difficult  to  distinguish 
the  condition  under  consideration  from  acute  or 
chronic  appendicular  inflammations.  This  is  true 
particularly  because  the  point  of  maximum  tender- 
ness may  often  be  located  in  the  right  ileocaecal  re- 
gion, and  parsBsthetic  sensations  may  occur  on  the 
inner  surface  of  the  right  thigh.  Flexion  of  the 
right  leg  at  the  hip  during  the  attacks  and  slight 
distention  of  the  right  ileocaecal  region  aid  in  confus- 
ing the  picture.  Occasionally  bladder  symptoms  are 
present,  due  to  pressure  of  the  full  bladder  upon  the 
inflamed  parts. 

Great  help  can  be  derived  in  such  a  confusion  of 
evidence  from  a  positive  diazo  reaction ;  in  contrast 
to  appendicitis,  too,  ulcerations  of  the  gut  even  dur- 
ing the  colicky  attacks  may  be  entirely  free  from 
temperature.  Added  to  this  we  may  have  a  previous 
history  of  long-continued  symptoms  of  slight  intes- 
tinal obstruction  and  the  general  evidences  which 
point  to  tuberculous  trouble,  night-sweats,  pul- 
monary symptoms,  etc. 

In  those  cases  in  which  the  stenosis  is  slight,  vis- 
ible peristalsis  is  often  limited,  and  is  noticeable  par- 
ticularly in  the  ileocsecal  region  and  in  the  immediate 
neighborhood  of  the  umbilicus.  The  peristalsis  is 
often  accompanied  by  crackling  sounds  produced  by 
the  passage  of  gas  through  the  stenosis,  which  is  fol- 
lowed by  relief  from  pain  as  the  pressure  upon  the 
overdistended  gut  is  diminished.  While  occasion- 
ally slight  chilly  feelings,  or  in  severe  cases  even  col- 
lapse, may  occur  in  this  condition,  a  true  shaking 
chill  is  extremely  rare. 


182  PAIN 

It  would  be  impossible  to  review  all  the  condi- 
tions which  make  a  differential  diagnosis  in  this  con- 
dition difficult.  It  is,  however,  advisable  to  be  sus- 
picious of  tuberculous  ulceration  of  the  gut  in  all 
those  cases  of  abdominal  pains  of  colicky  nature  in 
which  there  are  any  other  factors  in  the  history  or 
in  the  physical  examination  which  point  to  a  tubercu- 
lous tendency  in  the  patient. 

DISEASES   OF  THE  APPENDIX. 

It  is  not  wise  to  speak  in  a  vague  way  of  ' '  appen- 
dicular  colic."  The  acute  or  chronic  inflammatory 
conditions  of  the  appendix  originate  from  a  variety 
of  causes,  and  it  is  necessary  to  understand  clearly 
the  pathological  basis  of  the  pains  which  occur  in 
each  of  these  conditions  in  order  to  draw  diagnostic 
conclusions  from  them.  It  is  generally  assumed  that 
the  colicky  pains  in  appendicular  conditions  are 
primarily  due  to  the  intra-appendicular  pressure  of 
inflammatory  exudates,  which  cause  contractions  of 
the  musculature,  and  a  condition  not  unlike  neural- 
gia. This  is  an  assumption  which  has  much  in  its 
favor  and  cannot  be  dismissed  lightly.  This  explan- 
ation of  the  pains,  however,  is  entirely  insufficient 
for  the  more  chronic  conditions  where  the  appendix 
is  well  imbedded  in  the  surrounding  inflammatory 
thickenings.  Here,  of  course,  distention  of  its 
lumen  and  contraction  of  its  muscular  walls  are 
quite  out  of  the  question.  I  should  like  to  suggest 
that  it  is  quite  possible  that  many  of  these  so-called 
cases  of  appendicular  colic  are  nothing  more  than  a 


DIGESTIVE   SYSTEM  183 

simple  intestinal  colic  reflexly  initiated  in  the  appen- 
dix. In  these  cases  intestinal  inflammations  seem 
frequently  to  have  preceded,  the  attack  of  appendi- 
citis occurring  during  an  acute  exacerbation  of 
these.  This  assumption  would  be  supported  by 
the  frequency  with  which  the  parasitic  flora  of  the 
feces  is  changed  from  the  normal  in  cases  of  appen- 
dicitis, and  would  explain  the  previous  diarrhoeas 
which  often  are  present  during  the  early  develop- 
ment of  appendicitis. 

Comparison  of  the  pains  in  appendicitis  with 
those  in  tuberculous  ulceration  of  the  intestine 
shows  many  points  of  similarity.  Distinction  be- 
tween the  conditions  would  be  almost  impossible,  as 
far  as  the  pains  themselves  are  concerned,  were  it 
not  that  in  contrast  to  the  intestinal  pains  of  other 
diseases,  in  appendicitis  we  have  added  the  pains 
due  to  peritoneal  inflammation,  and  from  this  a 
number  of  important  differential  symptoms  can  be 
deduced. 

The  early  pains  of  appendicitis  rarely  corre- 
spond in  localization  to  the  position  of  the  appendix. 
Usually  the  pains  begin  diffusely  in  the  umbilical 
and  hypogastric  regions,  occasionally  in  the  epigas- 
trium, and  differ  in  nothing  from  the  pains  of  ordi- 
nary intestinal  colic  following  errors  of  diet,  or 
acute  gastro-enteritis.  The  suspicion  of  appendi- 
citis at  this  stage  is  not  aroused  by  the  character  of 
the  pains  but  depends  upon  the  secondary  symptoms, 
such  as  temperature,  etc.,  and  the  absolute  absence 
of  the  usual  causative  agents  of  intestinal  colic.  It 


184  PAIN 

is  only  the  rare  cases  which  begin  with  a  localized 
pain  over  the  appendix,  or  even  with  a  distinctly 
right-sided  pain.  Occasionally,  there  may  appear 
radiations  of  the  pain  into  the  right  inguinal  or 
lumbar  regions,  and  this  seems  to  depend  upon  a 
retrocaecal  position  of  the  appendix.  It  is  extremely 
important  in  these  cases  to  determine  whether  or 
not  there  is  radiation  into  the  right  thigh.  This  is 
not  often  found,  but  when  present  may  be  regarded 
as  characteristic  of  true  appendicular  colic,  since 
it  never  occurs  in  the  ordinary  pains  of  intes- 
tinal peristalsis.  The  more  irregularly  localized 
pains  which  occur  in  this  condition  are  probably 
never  entirely  of  appendicular  origin.  In  contrast 
to  them,  however,  we  have  pains  which  are  due  to 
the  localized  peritonitis  or  peri-appendicitis,  and 
these  are  situated  more  exactly  over  the  position  of 
the  appendix.  Extension  of  such  processes  and  the 
formation  of  abscesses  will  lead  to  pressure  pains 
in  the  right  inguinal  region,  as  well  as  to  extreme 
tenderness  upon  rectal  examination  (abscess  in  the 
pouch  of  Douglas).  These  local  peritonitic  pains 
are  very  sharply  denned,  and  are  of  extreme  im- 
portance in  differential  diagnosis. 

There  are  three  principal  elements  which  under- 
lie the  causation  of  pain  in  such  conditions,  which 
will  have  to  be  discussed  in  greater  detail. 

1.  PRESSURE. — There  is,  almost  invariably,  pain 
upon  pressure  in  the  ileocsecal  region  corresponding 
to  the  location  of  the  disease.  This  pain  is  subject 
to  wide  variations  in  intensity.  It  is  usually  great- 


DIGESTIVE  SYSTEM  185 

est  during  the  stage  of  abscess  formation,  when 
the  abscess  wall  is  subject  to  great  distention.  In 
such  cases  the  slightest  pressure,  even  the  weight  of 
the  bed-clothes,  will  be  marked  by  extreme  agony. 
Pain  upon  pressure  may  occasionally  exist  in  the 
right  flank  as  well,  especially  in  cases  where  abscess 
formation  occurs  retrocsecally.  When  the  tender- 
ness is  situated  high  up  under  the  right  costal  bor- 
der, it  is  probable  that  the  pain  is  chiefly  of  peri- 
toneal origin.  It  has  frequently  come  to  my  notice, 
however,  that  when  the  bowels  have  been  freely 
moved  by  an  enema  (for  instance,  five  grams  of  glyc- 
erin) the  sensitiveness  diminishes  immediately  upon 
reduction  of  the  distention.  This  indicates  unques- 
tionably that  the  pressure  of  the  distended  intes- 
tinal walls  upon  their  inflamed  serous  coverings 
may  play  an  important  role  in  the  mechanism  of 
these  pains;  this  may  also  explain  those  less  fre- 
quent cases  in  which  the  sensitiveness  to  pressure 
is  greater  over  the  left  half  of  the  abdomen  above 
Poupart's  ligament,  than  on  the  right,  intestinal 
distention  being  more  intense  on  that  side.  When 
the  appendix  itself  is  pressed  upon,  radiation  of  the 
pain  often  occurs  towards  the  epigastrium  and  into 
the  left  hypogastrium. 

We  have  already  considered  the  more  or  less 
traumatic  pains  produced  by  examination.  Spon- 
taneous movements  of  the  patient  produce  pain  in 
the  same  way,  especially  contraction  of  the  abdom- 
inal and  pelvic  muscles.  Thus  the  first  pains  fre- 
quently occur  in  the  ileocaecal  region  when  the 


186  PAIN 

patient  stoops,  sits  down,  sits  up  in  bed,  lifts  a 
weight,  or  bends  the  body  back  upon  the  hips. 
Sometimes  even  the  lifting  of  the  head  when  in  the 
prone  position  will  give  rise  to  pain.  More  particu- 
larly, however,  pain  is  caused  by  contracture  of  the 
right  ileopsoas  (produced  by  the  bending  of  the  right 
leg  upon  the  hip).  This  motion  gives  rise  to  pain 
in  the  ileocascal  region,  especially  severe  when  the 
abdominal  muscles  are  contracted.  The  pains, 
therefore,  would  be  greater  when,  the  patient  is 
standing,  walking,  or  climbing  stairs  than  when  he 
is  lying  down,  for  in  these  positions  the  diseased 
tissues  are  compressed  between  the  contracting  ileo- 
psoas and  the  contracting  abdominal  wall.  It  is 
important  to  remember  this  when  testing  pain  on 
flexion  of  the  right  leg,  for  even  during  the  exist- 
ence of  an  appendicitis  such  motion  of  the  right  leg 
when  the  patient  is  lying  down  may  be  entirely  with- 
out pain,  while  the  same  motion  may  be  very  painful 
when  the  patient  is  standing  or  walking.  Thus  this 
symptom  of  hip  flexion  is  entirely  dependent  upon 
the  position  of  the  body.  In  some  cases  it  can  be 
elicited  only  when  the  patient  is  lying  on  his  left  side. 
The  first  indication  of  appendicular  pain  has  often 
occurred  during  the  drawing  on  of  shoes,  and  here 
again  it  is  unquestionably  a  pressure  pain,  since  the 
patient  in  carrying  out  this  motion  lifts  the  right 
leg  and  produces  a  contraction  of  the  corresponding 
pelvic  muscles.  While  this  symptom  is  apparently 
trivial,  it  is  so  frequently  the  first  indication  of  early 
appendicular  trouble  that  it  may  become  extremely 
important  in  differential  diagnosis. 


DIGESTIVE   SYSTEM  187 

In  some  cases  of  early  appendicitis  the  pain  is 
markedly  increased  when  the  patient  is  lying  on  the 
right  side,  and  this  again  is  due  to  pressure  upon  the 
inflamed  parts.  Because  of  the  pain  caused  by  these 
muscular  contractions,  the  patient  involuntarily  re- 
laxes these  muscles  and  thus  many  patients  with 
appendicitis  bend  forward  when  walking  or  bend 
toward  the  right  side,  or,  when  lying  down,  draw  up 
the  right  thigh  and  arouse  by  their  very  position  the 
suspicion  of  appendicitis. 

2.  JARRING. — For  diagnostic  purposes  the  most 
practical  way  of  producing  jarring  of  the  abdomen  in 
the  ileocaecal  region  is  by  percussion.    With  its  help 
a  very  exact  demarcation  of  the  area  of  pain  can  be 
made,  and  it  is  much  to  be  preferred  for  this  purpose 
to  simple  palpation.     The  pathological  basis  of  pain 
produced  by  jarring  is  probably  the  same  as  that  of 
the  pressure  pains.    Percussion  in  the  mid-line  is 
often  more  painful  than  on  either  side  of  the  line  be- 
cause of  the  absence  in  this  location  of  muscular 
defenses.     Other  forces  which  actively  cause  jarring 
of  the  abdomen  are  coughing,  stepping  on  the  right 
leg  in  going  downstairs,  jumping,  etc.    In  all  these 
cases  pains  are  produced  in  the  appendicular  region 
which  are  of  a  sharp,  boring  nature.     This  method 
of  pain  production  is   frequently  possible  before 
other  symptoms  have  occurred. 

3.  DISPLACEMENT. — Under  this  heading  we  will 
consider  chiefly  those  tearing  pains  which  are  pro- 
duced in  certain  positions  of  the  body  by  the  weight 
of  the  diseased  organs.    It  is  not  surprising  that  the 


188  PAIN 

slightest  displacement  of  this  kind  should  cause  pain 
when  we  consider  that  we  are  dealing  with  fresh  in- 
flammatory adhesions.  This  must  be  our  interpre- 
tation of  the  pains  complained  of  by  patients  who 
are  unable  to  lie  upon  the  left  side,  and  who  inform 
us  that,  in  this  position,  they  feel  a  painful  drawing 
as  though  something  were  falling  from  the  right  to 
the  left  side.  When  the  peritoneal  process  has  ex- 
tended into  the  left  side  the  same  variety  of  pain 
may  be  caused  by  the  right-sided  position.  It  is 
clear  that  such  pains  must  be  primarily  influenced 
by  two  factors : 

(1)  The   closeness   with   which   the   abdominal 
organs  are  held  together.    For  instance,  when  the 
abdominal  muscles  are  flabby  and  weak,  and  the 
viscera  are  in  consequence  very  loosely  packed  to- 
gether, even  the  slightest  change  of  position  will 
give  rise  to  displacement. 

(2)  The  formation  of  a  tumor  in  the  ileocaecal 
region,  either  in  the  form  of  exudate  or  of  enlarged 
glands.    When  the  patient  is  lying  on  the  left  side 
the  weight  of  the  tumor  mass  will  exert  considerable 
traction,  a  traction  which  may,  however,  be  exerted 
by  the  weight  of  the  intestinal  contents  themselves. 

The  pains  described  in  the  foregoing  paragraphs 
are  all  referable  to  the  localized  peritoneal  inflam- 
mation. 

The  general  intestinal  pains  which  are  added 
to  those  of  more  purely  appendicular  origin  are 
difficult  of  interpretation.  It  is  not  easy  to  say 
whether  the  basis  of  these  lies  in  the  appendix  itself, 


DIGESTIVE   SYSTEM  189 

or  whether  they  are  to  be  regarded  as  an  accompany- 
ing intestinal  colic.  The  localization  of  these  colicky 
pains  aids  us  but  little  in  determining  this.  At  any 
rate,  it  seems  wise  to  restrict  the  term  "  appendicular 
colic ' '  to  those  cases  only  in  which,  with  other  symp- 
toms of  appendicitis,  sudden  colicky  pains  occur 
spontaneously  without  previous  reference  to  pre- 
vious dietetic  errors  or  other  causes. 

More  frequently,  however,  the  beginning  of  the 
colicky  attacks  is  directly  dependent  upon  intestinal 
disorders,  especially  those  following  errors  in  diet, 
and  it  would  be  hard  to  understand  how  such  influ- 
ences could  affect  the  appendix  itself.  The  fact  that 
diarrhoea  frequently  occurs  in  these  cases  points  to 
the  likelihood  that  we  are  often  dealing  with  an  acute 
or  an  exacerbated  chronic  enteritis  in  the  course  of 
which  changes  in  the  appendix  and  its  peritoneal  sur- 
roundings may  occur. 

The  diarrhoea  is  of  great  differential  importance 
since  it  occurs  frequently  in  early  appendicitis, 
whereas  constipation  is  the  rule  in  cases  of  lead 
colic,  gall-bladder  colic,  and  the  pains  of  pyloric 
disease  and  diseases  of  the  ureters.  This  is  likewise 
true  of  most  of  the  gastric  pains  (ulcer  and  hyper- 
chlorhydria)  which  may  in  other  respects  have  a 
superficial  similarity  to  appendicitis.  In  differen- 
tiating the  condition  from  the  ordinary  acute  inflam- 
mations of  the  small  and  large  intestines,  our  most 
important  aid  lies  in  the  localized  peritoneal  pains 
which  have  been  spoken  of  above;  of  special  impor- 
tance is  the  hip-flexion  symptom.  Help  may  be  de- 


190  PAIN 

rived  from  the  bladder  symptoms,  which  aid  us  in 
determining  the  existence  of  a  local  peritonitis. 
These  often  consist  of  pains  during  micturition; 
strong  pressure  is  required  to  expel  the  urine,  and 
occasionally  retention  of  urine  occurs. 

In  differentiating  the  intestinal  pains  produced 
by  the  ingestion  of  irritating  substances  or  by  flatus, 
we  are  aided  particularly  by  the  temperature. 

Occasionally  errors  are  made  in  cases  where  for- 
eign bodies,  introduced  per  os  or  per  anum,  give  rise 
to  a  suspicion  of  appendicitis,  the  similarity  being 
more  marked  because  of  the  increased  temperature. 
It  is  often  extremely  difficult  to  differentiate  appen- 
dicular  pains  from  those  produced  in  inflammatory 
diseases  of  the  female  genitals  (parametrium,  tubes, 
and  ovaries) ;  this  is  especially  true  because  often 
disease  of  the  adnexa  and  appendicitis  occur  to- 
gether. In  such  cases  only  a  very  exact  analysis  of 
the  pains  will  lead  to  a  correct  interpretation. 

The  pains  of  peritoneal  origin  in  both  of  these 
conditions  show  great  similarity.  In  a  general  way, 
however,  the  symmetrically  bilateral  location  of  the 
pain,  and  the  deeper,  pelvic  position  of  the  tender- 
ness will  point  more  directly  to  parametritis  than  to 
appendicitis.  The  influence  of  menstruation  upon 
the  pains  must  be  carefully  considered,  without  for- 
getting that  it  is  not  rare  for  adhesions  to  have 
formed  between  the  appendix  and  chronically  in- 
flamed ovaries,  and  that  the  existence  of  a  parame- 
tritis by  no  means  excludes  the  existence  of  an 
appendicitis. 


DIGESTIVE   SYSTEM  191 

Furthermore,  in  differentiating  between  these 
two  conditions  we  can  be  guided  by  the  fact  that 
enteric  pains  are  almost  never  present  in  diseases 
of  the  genitalia,  and  that  the  diet  is  entirely  without 
influence  upon  the  pain. 

Appendicular  colic  may  occasionally  be  simulated 
by  right-sided  ectopic  pregnancy.  During  rupture, 
pain  occurs  which  radiates  into  the  right  thigh  and 
is  accompanied  by  collapse  and  sensitiveness  of  the 
abdomen.  The  absence  of  temperature,  however, 
the  presence  of  acute  anasmia,  and  occasionally  bleed- 
ing from  the  genitals,  with  a  previous  history  of 
pregnancy,  and  the  discovery  of  a  periuterine  tumor, 
lead  us  in  the  right  direction. 

Occasionally  we  will  have  to  consider  in  the  dif- 
ferential diagnosis  torsion  of  a  right-sided  ovarian 
cyst,  hydrosalpinx,  etc.  In  women,  too,  in  the  ab- 
sence of  fever  and  leucocytosis,  it  is  necessary  to 
search  carefully  for  signs  of  hysteria,  especially  in 
the  abdominal  regions  (viz.,  analgesia  of  the  umbili- 
cal region).  It  is  absolutely  necessary,  however,  to 
analyze  carefully  the  various  factors  which  influence 
the  pain  in  these  cases,  for,  unquestionably,  a  true 
appendicitis  may  occur  in  an  hysterical  individual. 
When  we  consider  that  the  appendicular  pains  are 
distinctly  due  to  two  components,  on  the  one  hand 
a  local  peritonitis,  on  the  other  hand  a  colic,  it  is 
plain  that  other  inflammatory  processes  occurring 
in  the  ileocaecal  region  may  give  rise  to  the  same 
symptom  complex,  chief  among  these  being  tuber- 
culous, actinomycetic,  and  malignant  processes. 


192  PAIN 

Similarly  localized  tenderness  may  occasionally 
occur  in  diseases  of  the  kidney  and  gall-bladder,  in 
psoas  abscesses,  in  right-sided  pleurisy,  and  in 

pneumonia. 

LEAD  COLIC. 

When  sudden  attacks  of  colic  occur  in  an  anaemic 
individual  who  gives  a  history  of  dyspepsia,  ano- 
rexia and  constipation,  and  when  these  attacks  are 
localized  in  the  epigastrium  and  are  accompanied 
by  retraction  and  rigidity  of  the  abdominal  walls, 
our  first  thought  must  be  of  chronic  lead  poisoning. 
On  the  other  hand,  it  would  be  hasty  to  conclude 
from  the  coincidence  of  colicky  pains  and  the  signs 
of  chronic  plumbism  that  we  are  necessarily  dealing 
with  a  neuralgia  of  the  mesenteric  plexus  due  to  lead. 
Occasionally,  other  toxic  conditions  must  be  consid- 
ered, to  which  patients  with  lead  poisoning  are  par- 
ticularly predisposed.  Chief  among  these  is  nico- 
tine poisoning.  It  is  not  rare,  also,  to  find  tubercu- 
losis in  individuals  with  lead  poisoning,  and  in  such 
cases  we  may  well  be  dealing  with  tuberculous  ulcer- 
ations.  Again,  ulcerative  processes  in  the  stomach 
and  duodenum  are  not  infrequent  during  the  course 
of  lead  poisoning,  and  may  be  especially  favored  by 
the  condition  of  the  vessels  and  by  a  tendency  to 
spastic  contraction  in  the  stomach  and  intestinal 
canal.  Furthermore,  I  should  like  to  call  attention 
to  the  fact  that  in  cases  of  chronic  lead  poisoning 
there  is  sensitiveness  to  pressure  in  the  region  of 
the  appendix,  and  for  this  reason  also  the  question 
of  appendicitis  must  be  considered.  It  goes  without 


DIGESTIVE   SYSTEM  193 

saying,  furthermore,  that  chronic  lead  poisoning 
does  not  protect  against  the  colics  of  gall-stones  and 
renal  calculi.  It  becomes  necessary,  therefore,  in 
each  case,  to  consider  carefully  the  individual  symp- 
toms and  to  analyze  the  pains  as  they  occur. 

In  regard  to  the  factors  modifying  the  pains  we 
can  assume  that,  because  of  the  nervous  origin  of 
the  disease,  dietetic  influences  do  not  come  under 
consideration;  and,  as  a  matter  of  fact,  this  con- 
clusion is  justified  by  actual  fact.  The  pains  in  this 
condition  are  independent  of  dietetic  influences. 
This  is  in  contrast  to  the  state  of  affairs  found  in 
the  case  of  most  intestinal  pains  (tuberculous  ulcera- 
tions  and  stenosis  of  the  gut)  and  therefore  is  of  the 
greatest  differential  importance.  It  would,  how- 
ever, be  silly  to  expect  that  the  hyperaesthetic  gut  of 
chronic  lead  poisoning  may  not  react  forcibly  to 
errors  of  diet,  and  all  those  articles  of  food  which 
cause  much  flatus  may  in  these  cases  give  rise  to  true 
colic.  This,  of  course,  would  not  represent  a  true 
case  of  lead  colic,  but  would  simply  consist  of  a 
colica  flatulenta  favored  by  the  existing  lead  poison- 
ing. It  is  probable  that  in  a  great  many  cases  of 
so-called  lead  colic  the  pains  are  caused  by  the  pres- 
ence of  stagnated  fecal  material  and  abnormal  quan- 
tities of  gas,  and  thus  are  explained  the  frequent 
prompt  results  gained  therapeutically  by  high  ene- 
mata,  and  the  observation  frequently  made  by 
patients  that  the  passage  of  gas  immediately  relieves 
the  colic;  in  some  cases,  too,  relief  may  be  experi- 
enced from  vomiting. 

13 


194  PAIN 

Excessive  use  of  tobacco  is  unquestionably  an 
important  factor  in  the  initiation  and  increase  of 
the  colicky  pains,  a  consideration  which  is  worthy 
of  notice  therapeutically.  Alcohol  in  concentrated 
forms,  such  as  brandy,  in  many  cases  causes  diminu- 
tion of  the  pains.  Mechanical  agencies,  because  of 
the  neuropathological  basis  of  the  pains,  have  little 
influence. 

Changes  of  position  do  not  influence  the  pain  in 
these  cases  as  they  do  in  ulcerative  processes  or  in 
the  localized  peritoneal  inflammations.  It  is  fre- 
quently claimed  that  pressure  upon  the  abdomen  is 
not  painful  in  cases  of  lead  colic,  but  on  the  contrary 
often  relieves  pain.  This  is  true  in  a  great  many 
instances,  but  cannot  be  regarded  as  a  rule.  Pain 
on  pressure  may  frequently  be  due  to  the  fact  that 
there  exists  a  severe  neurasthenia  which  is  accom- 
panied by  general  hyperaesthesia.  In  those  cases 
where  gas  collects,  locally  or  diffusely,  in  the  intes- 
tinal tract  during  the  attacks,  it  is  perfectly  natural 
that  there  should  be  a  certain  amount  of  tenderness 
to  pressure  over  the  distended  intestinal  coils.  The 
sensitiveness  of  the  abdomen  to  pressure,  therefore, 
can  give  us  little  help  in  differentiating  this  condi- 
tion from  the  peritoneal  processes.  Flexion  of  the 
thighs  upon  the  abdomen  frequently  gives  relief; 
but  it  is  important  to  notice  whether  both  thighs  are 
flexed  or  whether  the  right  thigh  simply,  as  would 
be  the  case  in  appendicitis  or  in  the  tuberculous 
ulcerations  of  the  intestine. 

The  application  of  heat  usually  influences  the 
colic  favorably.    The  application  of  cold  often  ini- 


DIGESTIVE   SYSTEM  195 

tiates  an  attack.  Emotional  excitement  may  fre- 
quently give  rise  to  a  severe  attack  of  pain. 

The  pains,  which  are  chiefly  of  a  sharp,  boring  or 
cutting  character,  and  which  are  almost  invariably 
paroxysmal,  are  located  principally  about  the  um- 
bilicus. Occasionally,  however,  they  occur  in  the 
epigastrium.  When  the  attack  is  at  its  height  it  is 
hard  to  refer  the  pains  to  any  particular  region,  and 
they  may  cover  the  abdomen  diffusely.  The  pain  is 
as  a  rule  limited  to  the  abdominal  region  and 
only  in  the  rarest  cases  radiates  into  the  sternum, 
the  chest  and  the  shoulders.  On  the  other  hand, 
pain  frequently  occurs  in  the  lumbar  region,  and  may 
radiate  into  the  genitals  or  bilaterally  into  the  thighs 
(lead  colic  of  the  ureters).  There  is  no  radiation 
into  the  ileocaecal  region,  as  is  so  frequently  the  case 
in  tuberculous  ulcerations.  This  region,  however, 
and  occasionally  the  region  of  the  sigmoid  flexure 
are  often  quite  sensitive  to  pressure.  This  can  be 
easily  explained  by  the  fact  that  in  these  two  regions 
especially  there  is  apt  to  be  stagnation  of  the  feces 
which,  with  slight  inflammatory  changes,  leads  nat- 
urally to  tenderness. 

As  far  as  the  time  of  occurrence  of  these  pains 
is  concerned  we  are  able  to  gather  no  facts  of  differ- 
ential importance.  The  very  irregularity  of  the  at- 
tacks, which  often  show  prolonged  intervals  between 
separate  seizures,  should  give  us  some  clew.  Attacks 
occur  more  frequently  during  the  night  than  during 
the  day ;  but  this  peculiarity  is  common  to  all  varie- 
ties of  abdominal  colic. 


196  PAIN 

The  most  important  of  the  secondary  symptoms 
which  accompany  the  colicky  attacks  are  the  follow- 
ing: Nausea  and  vomiting,  often  an  absolute  intol- 
erance for  solid  or  fluid  food,  constipation  preceding 
the  attack,  sometimes  with  tenesmus,  usually  with 
retraction  of  the  abdominal  wall.  Visible  peristalsis 
and  succussion  are  rarely  present,  and  are  found 
only  in  those  cases  where  the  constipation  is  of  a 
very  chronic  order  and  where  the  abdominal  walls 
are  extremely  flabby.  There  are  practically  no 
alarming  general  symptoms.  The  diagnosis,  of 
course,  will  be  much  strengthened  by  the  discovery 
of  other  symptoms  of  chronic  lead  poisoning,  such 
as  a  lead  line,  weakness  of  the  muscles  supplied  by 
the  radical  nerve,  and  high  blood  pressure.  The 
high  blood  pressure  itself  is  by  no  means  constant 
in  these  cases,  since  it  may  even  be  diminished  in 
cases  where  the  anaemia  is  severe  or  where  tubercu- 
losis exists  as  a  complication. 

There  are  other  conditions  which,  resting  on  a 
purely  neuropathological  basis,  may  also  produce 
gastro-intestinal  colic,  and  from  these  we  must  occa- 
sionally differentiate  lead  colic.  Chief  among  these, 
of  course,  would  be  the  intestinal  crises  of  tabes, 
and  hi  such  cases  the  nervous  system  must  be  care- 
fully examined  in  order  to  make  the  differentiation. 

Ulcerations  of  the  gut  with  stenosis  may  give 
rise  to  difficulty  in  diagnosis.  Lead  colic  is  ex- 
cluded in  such  cases  by  the  close  relation  of  the  pains 
to  the  taking  of  food,  their  constancy,  and  their 
definite  variation  upon  changes  of  position.  The 


DIGESTIVE   SYSTEM  197 

discovery  of  sarcinae  in  the  vomitus  or  in  the  feces 
during  an  attack  would  point  quite  distinctly  to  the 
existence  of  pyloric  stenosis. 

In  distinguishing  lead  colic  from  appendicitis 
and  peritonitis,  our  chief  strongholds  are  the  afebrile 
course  and  the  absence  of  a  leucocytosis.  These  two 
conditions  carry  with  them  also  voluntary  immo- 
bilization of  the  abdomen  and  the  patient  usually 
assumes  a  supine  position,  whereas  in  lead  colic  the 
constant  restlessness  is  characteristic,  and  the 
patient  may  walk  about  or  remain  in  a  sitting  posi- 
tion, pressing  his  hands  upon  his  abdomen.  The 
indifference  of  the  patient  to  mechanical  disturb- 
ances of  the  abdomen  is  quite  characteristic  and 
helps  very  much  in  differentiating  lead  colic  from 
other  conditions.  This  aid  is  lost,  however,  in  those 
cases  mentioned  above  of  neurasthenic  patients,  who 
occasionally  show  abdominal  sensitiveness. 

In  closing,  it  is  necessary  to  call  attention  again 
to  the  fact  that,  even  when  chronic  lead  poisoning 
can  be  definitely  diagnosed,  the  possibility  of  a  com- 
plicating gastric  ulcer  or  renal  calculus  must  not 
be  overlooked. 

MALIGNANT   NEW   GROWTHS    OF   THE   INTESTINE. 

There  is  nothing  absolutely  characteristic  about 
the  pains  occurring  in  the  conditions  we  are  about 
to  discuss.  They  may  be  caused  by  organic  changes 
and  mechanical  stenosis  of  the  gut,  and  the  disten- 
tion  and  increased  peristalsis  dependent  upon  these. 
Or,  again,  their  pathological  basis  may  rest  chiefly 


198  PAIN 

upon  peritoneal  involvement.  The  pains  are  impor- 
tant, nevertheless,  from  a  diagnostic  point  of  view, 
in  that  they  frequently  occur  during  the  very  early 
stage  of  the  condition  when  other  physical  signs  are 
entirely  lacking. 

These  pains  are  frequently  regarded  as  harmless 
manifestations  of  intestinal  indigestion  such  as  fol- 
low errors  in  diet  or  exposure  to  cold,  and  yet  if  the 
phenomena  of  the  pains  are  carefully  analyzed  we 
may  often  find  distinct  reasons  for  believing  that 
there  is  a  well-localized  cause  for  the  attacks. 
Whenever  this  can  be  accomplished  an  important 
diagnostic  advance  has  been  made. 

Corresponding  with  the  localized  process  from 
which  they  arise,  there  is  a  tendency  in  such  cases 
towards  a  localization  of  the  pains.  This  is  par- 
ticularly true  of  the  neoplasms  of  the  large  intestine 
where  frequently,  at  the  very  beginning  of  the  at- 
tacks, the  pain  is  felt  in  the  seat  of  the  lesion,  and,  in 
consequence,  usually  occurs  in  the  cascum  or  in  the 
three  flexures  of  the  large  gut.  At  the  height  of  such 
an  attack  the  pain  is  generally  diffuse,  but  centers 
chiefly  in  the  region  of  the  umbilicus,  and  is  fre- 
quently accompanied  by  pain  in  the  lumbar  regions. 
Whenever  the  obstructing  process  lies  in  the  neigh- 
borhood of  the  splenic  flexure  there  may  be  distinct 
radiation  into  the  lower  half  of  the  thorax  and  occa- 
sionally, though  rarely,  into  the  left  leg  (one  case 
of  hysteria).  When  the  neoplasm  occurs  in  the 
hepatic  flexure  the  condition  may  strikingly  simulate 
gall-bladder  colic.  The  pains  begin  in  the  neighbor- 


DIGESTIVE   SYSTEM  199 

hood  of  the  gall-bladder,  radiate  backwards  into  the 
small  of  the  back,  and  frequently  reach  even  to  the 
right  shoulder  blade.  Radiation  towards  the  anus  is 
a  phenomenon  of  extreme  importance,  for  it  indicates 
most  frequently  a  deep-seated  carcinoma  of  the  sig- 
moid  flexure.  Occasionally  it  may  accompany  new 
growths  which  are  situated  higher  up  in  the  colon, 
but  whenever  it  is  present  it  appears  to  the  writer 
to  be  a  most  important  sign  of  stenotic  processes 
in  the  large  intestine.  In  carcinoma  of  the  sigmoid 
flexure  and  rectum  a  more  distinct  localization  can 
often  be  made.  When  the  process  is  situated  in 
these  regions  there  are  frequently  dull  pains  in  the 
left  inguinal  region  which  radiate  into  the  left  tes- 
ticle. Again  pains  may  arise  in  the  left  half  of  the 
epigastrium  and  radiate  towards  the  anus ;  radiation 
into  the  left  inguinal  region  and  along  the  outer 
aspect  of  the  left  thigh  occurs  and  seems  to  be  a 
particular  accompaniment  of  left-sided  tumors. 
Pains  in  the  back  are  rarely  present,  or  when  occur- 
ring are  simply  added  to  the  sum  of  the  other  pains. 
The  same  may  be  said  of  pains  in  the  region  of  the 
left  sciatic  nerve. 

Not  less  important  than  the  topographical  consid- 
erations are  those  symptoms  which  give  us  a  clew 
to  the  factors  influencing  the  pains,  and  these  aid  us 
particularly  in  differentiating  the  localized  carcino- 
matous  processes  from  those  occurring  in  acute  or 
chronic  enteritis. 

It  appears  to  me  of  special  importance,  when- 
ever intestinal  colic  occurs  in  older  people,  to  deter- 


200  PAIN 

mine  whether  there  is  a  "position  of  the  greatest 
pain, ' '  such  as  that  which  we  have  considered  in  the 
discussion  of  the  pains  accompanying  ulcers.  When 
we  are  dealing,  for  instance,  with  a  carcinomatous 
process  in  the  region  of  the  hepatic  flexure,  the 
patients  will  frequently  tell  us  that  they  cannot  lie 
comfortably  upon  the  left  side  because  in  this  posi- 
tion they  have  pains  in  the  right  side  which  give 
them  the  impression  of  a  mass  dropping  from  right 
to  left.  This  is  unquestionably  in  many  cases  due 
to  traction  upon  peritoneal  adhesions  and  therefore 
points  strongly  towards  the  extension  of  a  local 
process.  The  occurrence  of  such  an  extremely  im- 
portant diagnostic  position  of  pain  is  not  infre- 
quently noticeable  at  an  earlier  stage  than  the  occur- 
rence of  any  local  sensitiveness  to  palpation.  It  is 
always  important  to  examine  the  abdomen  carefully 
for  sensitiveness  to  local  pressure,  since  in  many 
cases  pains  may  be  produced  in  this  way,  which  then 
give  an  important  clew.  Absence  of  abdominal  ten- 
derness does  not,  of  course,  exclude  absolutely  the 
condition  under  consideration,  for  sensitiveness  to 
pressure  may  be  absent  in  those  neoplasms  which 
are  situated  in  the  pelvis,  in  the  neighborhood  of  the 
rectum  and  in  the  lower  half  of  the  sigmoid  flexure. 
Local  sensitiveness  corresponding  to  the  seat  of  the 
tumor  is  occasionally  felt  during  strong  contraction 
of  the  abdominal  muscles,  such  as  that  produced  by 
lifting  a  weight  or  in  defecation.  Deep  diaphrag- 
matic inspiration  may  give  rise  to  such  pain,  espe- 
cially in  cases  where  peritoneal  inflammations  are 


DIGESTIVE  SYSTEM  201 

present.  The  same  kind  of  pain  may  be  elicited  by 
careful  inflation  of  the  rectum.  Whenever  pains 
are  present  in  the  lumbar  region  these  are  increased 
by  stooping. 

The  peculiarities  of  the  pain  in  cases  of  malig- 
nant tumors  which  we  have  so  far  enumerated,  have 
a  diagnostic  significance  chiefly  because  they  lead 
us  to  suspect  a  localized  cause  for  the  attacks  of 
colic,  and  therefore  considerably  limit  the  diagnostic 
field.  For,  by  reaching  such  a  conclusion,  we  are 
able  to  exclude  a  great  many  of  the  more  generalized 
causes  for  intestinal  colic,  such  as  the  conditions 
caused  by  flatulence  and  the  ordinary  intestinal  in- 
digestion. The  differentially  significant  phenomena 
in  the  case  of  neoplasms  are  based  upon  the  early 
occurrence  of  a  local  peritonitis,  giving  rise  to  the 
occurrence  of  a  position  of  the  greatest  pain,  and  to 
local  sensitiveness.  No  specific  or  characteristic 
factors,  of  course,  can  be  ascribed  to  those  phenom- 
ena which  depend  upon  flatulence  and  consequent 
distention  of  the  gut,  or  upon  the  increased  peristal- 
tic contractions  of  the  intestinal  muscles.  If  the 
symptoms  depending  upon  these  conditions  are  par- 
ticularly prominent  they  lead  easily  to  confusion 
with  other  conditions.  However,  these  general  pains 
will  aid  very  much  in  differentiating  the  conditions 
we  are  speaking  of  from  colicky  attacks  occurring 
with  diseases  of  other  organs.  This  would  be  par- 
ticularly important  in  cases  such  as  carcinoma  of 
the  hepatic  flexure  where  the  confusion  with  gall- 
bladder colic  is  very  easy,  and  where  such  general 


202  PAIN 

intestinal  symptoms  protect  us  from  mistaking  one 
condition  for  the  other.  This  becomes  especially 
significant  when  we  consider  how  frequently  even 
the  secondary  symptoms  of  these'  two  conditions 
(fever  and  slight  jaundice)  are  common  to-  both. 

When,  in  intestinal  new  growths,  the  attacks  of 
pain  are  dependent  chiefly  upon  the  general  intes- 
tinal condition,  their  onset  may  frequently  be  directly 
related  to  some  thermic  stimulation,  such  as  the 
application  of  cold,  walking  with  bare  feet  upon  a 
cold  floor,  sudden  throwing  off  of  the  bed-clothes  or 
drinking  cold  fluids.  The  reason  for  this  is  a  stimu- 
lation of  peristalsis.  Again,  the  attacks  of  pain  may 
be  incited  by  articles  of  diet  which  increase  the  pro- 
duction of  gas  in  the  intestine,  such  as  certain  vege- 
tables, bread,  etc.,  and  frequently  in  the  history  of 
intestinal  carcinoma  the  first  attack  of  pain  is 
directly  referable  to  such  errors  of  diet.  It  is  well 
to  remember  these  things  in  order  to  protect  our- 
selves against  mistaking  the  early  symptoms  of  a 
carcinoma  for  simple  intestinal  colic,  and  it  is  espe- 
cially desirable  when  dealing  with  older  individuals 
to  search  carefully  for  the  existence  of  a  new  growth 
even  when  the  colicky  pains  seem  to  have  been 
directly  connected  with  an  error  in  diet. 

It  frequently  happens  that  the  positive  physical 
signs  are  delayed  for  a  long  period  after  these  first 
subjective  symptoms  have  been  noticed.  In  those 
cases  where  the  above-mentioned  subjective  symp- 
toms are  absent,  but  where  we  have  some  other 
reason  to  suspect  the  existence  of  a  neoplasm,  it  is 


DIGESTIVE   SYSTEM  203 

well  to  attempt  by  palpation  and  by  changes  of  posi- 
tion to  produce  artificially  the  conditions  most  favor- 
able to  the  production  of  the  pains ;  and  in  this  way 
we  may  be  led  to  a  clearer  comprehension  of  the 
case. 

An  important  symptom  which  is  frequently  pres- 
ent in  these  cases  is  prolonged  constipation.  The 
passage  of  feces  or  gas  from  the  intestine  is  usually 
followed  by  an  immediate  diminution  of  the  pains. 
The  patients  themselves  frequently,  during  the  at- 
tacks of  colic,  massage  the  abdomen  in  the  region 
corresponding  to  the  position  of  the  tumor  in  order 
to  diminish  their  pains.  Thus  the  distribution  of 
the  distention  which  is  probably  the  cause  of  the 
pain  actually  leads  to  great  relief.  Occasionally, 
even,  the  definite  localization  of  the  spontaneous 
massage  carried  on  by  the  patient  will  be  of  diag- 
nostic aid. 

While  there  is  generally  no  distinct  relation  be- 
tween the  attacks  of  pain  and  the  taking  of  food, 
occasionally  there  does  exist  some  regularity  in  their 
occurrence  in  relation  to  the  large  meal.  In  some 
cases  attacks  occur  within  two  to  three  hours  after 
the  meal,  and  are  probably  directly  dependent  upon 
the  occurrence  of  powerful  peristalsis  during  this 
time.  This  same  interpretation  may  be  given  to  the 
frequency  of  nocturnal  attacks.  During  early  car- 
cinoma there  are  usually  intervals  of  several  months 
between  the  attacks  of  pain.  As  the  disease  pro- 
gresses the  intervals  become  shorter  and  shorter, 
a  fact  which  may  have  much  diagnostic  significance, 


204  PAIN 

since  these  intervals  depend  upon  the  nature  of  the 
process.  Frequently  the  pains  occur  a  short  time 
before  defecation.  This  is  chiefly  the  case  in  those 
carcinomata  which  are  situated  well  down  under  the 
sigmoid  flexure. 

The  symptoms  which  occasionally  accompany  the 
pains  due  to  intestinal  neoplasms  are  often  of  such 
a  nature  that  their  erroneous  interpretation  might 
well  lead  to  false  localization  of  the  disease  in  the 
stomach,  the  gall-bladder,  the  kidneys,  etc.  Thus 
vomiting  is  frequently  present  at  the  height  of  the 
attack,  and,  with  it,  appear  epigastric  pains.  The 
suspicion  of  gastric  disease  aroused  by  these  symp- 
toms can  be  allayed  by  remembering  that  whenever 
vomiting  occurs  in  intestinal  neoplasms  we  may  pre- 
suppose a  considerable  degree  of  stenosis  and  may, 
therefore,  expect  such  vomiting  to  be  accompanied 
by  visible  or  palpable  intestinal  peristalsis.  When 
the  vomitus  is  bile-stained,  is  foul,  or  contains  B. 
coli,  we  will,  of  course,  be  led  to  recognize  the  intes- 
tinal character  of  the  condition. 

In  carcinoma  of  the  splenic  flexure  pains  fre- 
quently occur  immediately  after  the  taking  of  food, 
and  are  caused  either  by  inflammatory  adhesions  to 
the  stomach,  or  by  direct  invasion  of  that  organ. 
In  such  cases  careful  distention  of  the  rectum  will 
usually  give  rise  to  immediate  pains  in  the  region 
of  the  splenic  flexure.  The  pains  of  carcinomata  of 
the  hepatic  flexure  are  frequently  confused  with 
gall-bladder  colic,  especially  when  the  pain  is  local- 
ized over  the  gall-bladder,  because  of  adhesions  or 


DIGESTIVE   SYSTEM  205 

direct  metastatic  growth.  Icterus  is  often  present 
in  these  cases,  and  a  sensation  of  resistance  in  the 
neighborhood  of  the  gall-bladder  may  be  felt.  In 
such  cases,  as  we  have  mentioned  before,  especial 
attention  must  be  paid  to-  the  influence  which  the 
application  of  cold  exerts  upon  the  production  of 
peristalsis  and  to  the  presence  of  visible  peristalsis 
or  succussion  in  the  ascending  colon.  The  tendency 
to  diarrhoea,  the  occasional  foul  stools  containing 
mucus,  and  the  presence  of  blood  or  of  an  abnormal 
flora  in  the  feces,  are  additional  evidences  pointing 
to  carcinoma.  The  local  bulging  which  might  occur 
in  the  neighborhood  of  the  gall-bladder  when  the 
intestine  in  this  vicinity  is  abnormally  distended 
could  very  easily  be  misinterpreted  as  a  large  gall- 
bladder. Chills  occur  in  this  form  of  intestinal 
carcinoma  also,  just  as  they  occur  in  gall-bladder 
colic.  In  some  cases,  especially  in  carcinomata  of 
the  sigmoid  flexure  or  the  caecum,  difficulty  in  urina- 
tion, pain  in  the  bladder,  frequent  micturition,  and 
even  radiation  into  the  testicle  may  be  present,  and 
these  may  easily  lead  to  false  conclusions.  In  this 
connection  it  is  simply  necessary  to  remember  the 
danger  of  error  and  to  avoid  it  whenever  the  tumor 
is  impalpable  and  visible  peristalsis  is  absent  by 
careful  examination  of  the  stools  and  the  peculiari- 
ties of  defecation,  such  as  tenesmus  and  distention 
of  the  descending  colon. 

In  differentiating  carcinomatous  disease  of  the 
intestine  from  the  other  more  distinctly  enteric 
causes  of  colic  (flatulence,  intestinal  indigestion,  etc.) 


206  PAIN 

we  have  already  called  attention  to  the  fact  that  a 
careful  analysis  of  the  pain  alone  may  give  us  much 
basis  for  a  sharp  localization  of  the  pathological 
condition.  A  distinct  recognition  of  this,  if  we  con- 
sider the  relatively  limited  number  of  such  localized 
processes  in  the  intestinal  tract,  will  make  the  fur- 
ther differential  diagnosis  quite  simple,  for  there 
are  few  ulcerative  or  stenotic  conditions  with  well- 
localized  symptoms  which  are  of  practical  impor- 
tance. Thus,  in  the  ileocascal  region  we  have,  outside 
of  carcinoma,  to  deal  almost  exclusively  with 
tuberculosis;  in  the  sigmoid  flexure,  almost  exclu- 
sively with  dysentery  or  occasionally  membranous 
enteritis. 

LIVER. 

There  are  three  chief  factors  which  give  rise  to 
pain  in  the  region  of  the  liver.  These  may  be  dis- 
cussed in  three  groups,  as  follows : 

I.  CONDITIONS  OF  SPASM  OK  DISTENTION  IN  THE 
BILE-PASSAGES  AND  GALL-BLADDER. 

The  pains  occurring  in  this  region  are  closely 
analogous  to  those  occurring  in  the  gastro-intestinal 
tract — a  fact  which  is  not  surprising  when  we  con- 
sider the  great  similarity  between  the  two  systems 
functionally  and  anatomically.  As  in  the  intestinal 
tract,  a  simple  narrowing  in  the  system  of  bile  ducts 
is  followed  by  spasm  and  overdistention  in  front  of 
the  stenosis,  which  consequently  give  rise  to  colicky 
pains.  Thus  here,  too,  colicky  pains  may  be  caused 
without  absolute  anatomical  occlusion  of  the  lumen. 


DIGESTIVE  SYSTEM  207 

While  such  attacks  of  gall-bladder  colic  are  usually 
associated  with,  the  presence  of  gall-stones,  this  is 
not  by  any  means  necessary,  and  it  is  illogical  to 
speak  invariably  of  such  attacks  as  gall-stone  colic. 

Further  analogy  to  the  conditions  in  the  alimen- 
tary canal  is  found  in  the  fact  that  inflammatory 
processes  without  any  existing  organic  stenosis  may 
be  accompanied  by  the  same  attacks  of  pain,  the  con- 
ditions for  such  attacks  being  especially  favorable 
in  the  appendix  to  the  gall-duct  system — the  gall- 
bladder. Here  a  colicky  attack  may  be  initiated  by 
an  inflammatory  exudation  with  a  rapidly  increasing 
intravesical  pressure  and  overdistention  of  the  walls. 
In  discussing  the  conditions  in  the  biliary  system 
which  can  give  rise  to  spasms  and  overdistention, 
with  their  consequent  attacks  of  colic,  we  shall  have 
to  consider : 

(a)  Stenosis  due  to  carcinoma  at  the  papilla  of 
Vater  or  in  the  head  of  the  pancreas,  ascarides  in 
the  ductus  choledochus,  aneurysms  of  the  hepatic 
artery,  intrahepatic  carcinoma,  cysts  and  gummata, 
kinking  of  the  cystic  duct  in  enteroptosis  by  adhe- 
sions, etc. 

(b)  Inflammation,   as   in   cholangeitis   with   or 
without    biliary    cirrhosis,    acute    yellow    atrophy, 
cholecystitis  with  or  without  the  formation  of  stones, 
carcinoma,  etc. 

It  is  hardly  necessary  to  mention  that  occasion- 
ally attacks  of  colic  may  be  initiated  by  a  combina- 
tion of  (a)  and  (b).  It  is  a  universal  rule  that 
wherever  secretions  accumulate  because  of  the  for- 
mation of  a  stenosis  the  opportunity  for  infection 


208  PAIN 

and  for  the  development  of  a  "stagnation-flora"  is 
particularly  favorable. 

It  would  probably  be  very  advisable  to  drop  the 
expression  gall-stone  colic  entirely,  and  to  substitute 
for  it  the  words,  gall-bladder  colic  or  gall-duct  colic, 
terms  which  imply  no  premature  anatomical  diag- 
nosis. This  may  seem  pedantic,  because  in  the  ma- 
jority of  these  cases  stones  are  actually  present,  but 
this  slow  method  of  diagnosis  seems  to  the  writer 
extremely  desirable,  since  by  its  use  we  may  often 
avoid  overlooking  other  and  rarer  causes  for  these 
attacks. 

II.    DiSTENTION  OF  THE  LlVEB   CAPSULE. 

Whenever  a  free  flow  of  blood  out  of  the  hepatic 
veins  is  prevented,  a  swelling  of  the  liver  results 
which  leads  to  painful  distention  of  the  peritoneal 
coverings.  A  similar  condition  is  caused  by  obstruc- 
tion to  the  flow  of  bile.  The  presence  of  cysts  in  the 
liver  tissue,  and  the  growth  of  neoplasms,  may  give 
rise  to  a  similar  result.  Distention  of  the  capsule 
of  the  liver  may  also  be  produced  by  active  hyper- 
semia.  Thus  in  malaria,  pernicious  anaemia,  par- 
oxysmal haemoglobinuria,  leukaemia,  diabetes,  this 
occasionally  occurs.  In  the  last-named  condition, 
however,  the  sensitiveness  to  pressure  is  usually  of 
very  moderate  degree. 

III.  INFLAMMATORY  PROCESSES  IN  THE  CAPSULE  OF 
THE  LIVER  (LOCAL  AND  DIFFUSE  PERIHEPATITIS). 

The  general  diagnosis  of  a  hepatalgia  is  based 
chiefly  upon  the  discovery  of  sensitiveness  to  pres- 


DIGESTIVE   SYSTEM  209 

sure  or  percussion,  upon  the  size  of  the  organ  as 
determined  by  the  liver  dullness  and  upon  a  close 
analysis  of  the  subjective  pains. 

It  now  becomes  our  task  to  analyze  more  closely 
the  details  of  the  mechanism  of  these  pains.  In 
doing  this  we  shall  find  that  the  groups  which  we 
have  just  discussed  will  often  act  in  combination. 

I.  Gall-bladder  Colic. 

It  is  plain,  from  the  very  pathological  conditions 
underlying  the  pains  occurring  in  diseases  of  this 
organ,  that  the  general  phenomena  must  frequently 
be  of  an  extremely  complicated  nature.  Thus,  ad- 
hesions between  the  gall-bladder  on  the  one  hand,  and 
the  duodenum  or  colon  on  the  other,  may  give  rise 
to  entirely  independent  attacks  of  pain ;  the  develop- 
ment of  peritonitis,  the  occurrence  of  septic  throm- 
bosis in  the  lower  extremities,  with  the  pains  that 
occur  in  them  simulating  radiation  from  the  original 
seat  of  trouble,  offer  extreme  difficulties  to  inter- 
pretation. It  must  also  be  remembered  that,  at  the 
height  of  the  attacks,  neurasthenic  patients  may 
experience  most  unusual  radiations  of  pain  into 
the  left  arm  or  into  the  right  leg,  so  that  in  judging 
of  the  condition  it  is  especially  important  to  pay 
attention  to  the  pains  which  have  occurred  at  the 
very  beginning  of  the  attack. 

The  usual  locations  of  the  earliest  pains  are  in 
the  epigastrium,  in  its  middle  portion  or  just  below 
the  right  costal  margin.  Whenever  the  attack  of 
colic  is  localized  chiefly  on  the  left  half  of  the  epi- 

14 


210  PAIN 

gastrium  we  will  be  much  more  apt  to  think  of  a 
simple  gastralgia  (excepting,  of  course,  in  cases  of 
transposition  of  the  organs).  The  natural  explana- 
tion of  this  right-sided  position  of  the  pain  is  found 
in  the  topography  of  the  gall-bladder  and  the  liver. 

The  pain  most  usually  radiates  from  the  epigas- 
trium upwards,  in  rare  cases  up  to  the  right  half 
of  the  neck  and  to.  the  right  acromion  process.  More 
often,  however,  it  radiates,  in  front,  up  to  the  right 
nipple  and  backwards  into  the  shoulder  blade  and 
into  the  right  lumbar  region.  The  radiations  which 
occasionally  occur  into  the  right  arm  and  leg,  or  even 
into  the  left  arm,  are  present  only  at  the  height  of 
very  intense  attacks  of  colic,  and  only  in  patients 
who  are  of  unusually  neurotic  constitution.  The 
paraesthesias  which  occur  occasionally  in  the  arms  are 
probably  of  a  vasomotor  nature.  "Whenever  the 
radiations  into  the  left  arm  are  prominent  we  must 
consider  the  possibility  that  the  attack  of  gall- 
bladder colic  by  increasing  the  blood  pressure  has 
brought  on  secondarily  an  attack  of  true  functional 
or  organic  angina  pectoris. 

Radiations  into  the  genitals  with  retention  of 
urine  and  severe  pains  above  the  symphysis  occur 
but  rarely,  but  when  they  do  occur  usually  depend 
upon  the  development  of  the  peritonitis  which  occa- 
sionally accompanies  the  gall-bladder  inflammation ; 
pains  in  the  lower  extremities,  especially  those  which 
occur  in  the  nerves  of  the  legs,  are  frequently  due 
to  septic  thrombi.  Such  complications  must  be  very 
carefully  considered  in  order  that  we  may  avoid  any 


DIGESTIVE   SYSTEM  211 

confusion  with  renal  calculi.  It  is  only  at  the  very 
height  of  the  attacks  that  the  pains  are  diffuse  or 
lack  definite  localization. 

While  the  localization  of  these  subjective  pains 
is  extremely  important,  just  as  much  help  can  be 
obtained  by  a  careful  determination  of  those  areas 
which  are  tender  to  palpation  and  percussion. 

1.  THE    GALL-BLADDER    ITSELF. — This    organ    is 
often  enlarged  and  is  usually  markedly  tender  to 
palpation  and  percussion.     There  are  certain  pecu- 
liarities connected  with  this  tenderness,  the  pres- 
ence of  which  confirms  the  diagnosis  of  gall-bladder 
tumor  and  aids  in  distinguishing  it  from  the  lower 
pole  of  the  kidney.    Pressure  upon  the  gall-bladder 
frequently  produces  radiation  of  the  pain  along  the 
phrenic  nerve  towards  the  acromion.    Radiations 
backward  towards  the  left  half  of  the  epigastrium 
and  towards  the  ensiform  process  are  quite  frequent. 
This  artificially  produced  radiation  is  an  important 
adjunct  to  the  spontaneous  radiations. 

2.  THE  MID-LINE  OF  THE  EPIGASTRIUM  FROM  THE 
ENSIFORM  TO  THE  EDGE  OF  THE  LIVER. — In  this  region, 
corresponding  to  the  area  of  liver  dullness,  limited 
below  by  the  edge  of  the  liver,  there  is  in  almost  all 
cases  of  early  gall-bladder  colic  marked  tenderness 
to  percussion.    In  those  cases  which  are  accompa- 
nied by  icterus,  this  tenderness  may  remain  for  a  long 
while  after  the  end  of  the  attack  of  colic  and  may, 
by  its  diminution,  indicate  an  improvement  in  the 
accompanying  pathological  changes.     This  symptom 
of  tenderness  to  palpation  in  the  mid-line  which 


212  PAIN 

occurs  in  cases-  of  gall-duct  colic  is  directly  referable 
to  increase  of  intrahepatic  pressure,  and  will  receive 
further  attention  in  the  section  on  hepatic  conges- 
tion. 

3.  THE  BIGHT  LUMBAR  REGION  (LIMITED  ABOVE  BY 
THE  BASE  OF  THE  LUNG). — Here  we  are  dealing  with 
a  symptom  which  frequently  remains  for  some  time 
after  the  attack  proper  has  ended,  and  has  probably 
the  same  etiological  causes  as  the  symptom  just 
described  under  2.  In  order  to  determine  the  pres- 
ence of  this  symptom  it  is  best  to  tap  lightly  with 
the  ulnar  surface  of  the  fist  upon  both  lumbar  re- 
gions in  order  to  compare  the  tenderness  of  the  two 
sides. 

In  addition  to  these  well-localized  areas  of  pain 
there  are  other  varieties  of  pain  which  undoubtedly 
are  of  reflex  origin  (phrenic  nerve,  etc.). 

(a)  Tenderness  in  the  area  of  the  shoulder 
girdle.  There  is  great  tenderness  to  pressure  in  the 
right  brachial  plexus ;  this  symptom  is  rare.  More 
frequently  there  is  a  point  of  sensitiveness  situated 
along  the  upper  portion  of  the  trapezius  muscle, 
about  three  fingers'  breadth  distant  from  the  acro- 
mion.  Pressure  at  this  point  causes  pain  which 
radiates  towards  the  gall-bladder.  Pressure  upon 
the  gall-bladder,  on  the  other  hand,  may  cause  pain 
radiating  towards  this  point.  There  exists  thus  a 
mutual  radiation  from  one  point  to  the  other. 

The  pains  we  have  just  discussed  are  not  fre- 
quent in  their  occurrence,  but  when  they  are  present 
they  may  be  of  considerable  importance  in  differen- 


DIGESTIVE   SYSTEM  213 

tiating  these  conditions  from  other  similar  attacks 
of  colic,  such  as  those  of  pyloric  stenosis,  etc.  They 
are  also  found,  however,  in  cases  of  liver  abscess, 
and  in  general  in  all  cases  of  subdiaphragmatic 
inflammations. 

(b)  Tenderness  to  palpation  along  the  vertebral 
column.  There  is  no  localized  tenderness  over  any 
one  particular  spinous  process.  The  hyperassthetic 
zone  extends  usually  over  several  spinous  processes 
and  is  commonly  subject  to  great  variations,  but,  in 
general,  it  occurs  between  the  fourth  and  the  twelfth 
thoracic  vertebrae.  Occasionally  there  may  be  ten- 
derness to  pressure  in  the  ileocsecal  region.  This, 
when  present,  is  not  easy  to  interpret.  Probably  in 
most  cases  it  is  a  direct  transmission  of  the  pressure 
upwards,  and  thus  in  reality  a  true  gall-bladder  pain. 
On  the  other  hand,  we  must  remember  that  in 
patients  with  gall-stone  disease,  and  liver  disease  in 
general,  there  are  usually  intestinal  disturbances, 
chiefly  chronic  constipation,  and  it  is  necessary  for 
us  therefore  to  think  of  chronic  inflammatory  con- 
ditions of  the  appendix. 

In  order  clearly  to  differentiate  between  gall- 
bladder colic  and  attacks  of  paroxysmal  pain  from 
other  causes,  it  is  necessary  to  pay  very  close  atten- 
tion to  the  gradual  increase  and  decrease  of  the 
attacks  and  to  the  cramp-like,  sharp  character  of 
the  pain.  In  those  cases  in  which  stone  formation 
is  present  this  characteristic  of  a  rapid  rise  to  a 
climax  and  gradual  decrease,  is  especially  marked, 
and  the  intensitv  of  the  attack  seems  to  reach  its 


214  PAIN 

maximum  at  the  time  when  the  stone  is  expelled. 
There  are  cases  which  have  a  more  chronic  and 
latent  character  and  which  in  the  course  of  years 
may  have  no  sharp  attacks,  but  in  which  there  is  a 
constant  sensation  of  soreness  in  the  epigastrium. 
Such  cases  of  gall-stones  without  actual  colic  usually 
occur  together  with  enteroptosis,  and  these  run  their 
course  with  constant  parassthetic  sensations  in  the 
region  of  the  epigastrium.  The  weakness  of  the 
abdominal  muscles,  as  well  as  possible  relaxation  of 
the  musculature  of  the  gall-ducts  may  be  responsible 
for  this. 

The  attacks  of  colic  may  occasionally  be  preceded 
and  followed  by  pains  of  another  nature.  These  are 
usually  sharp,  cutting  sensations  which  are  directly 
dependent  upon  deep  breathing  and  coughing,  and 
which  are  due  to  inflammatory  changes  about  the 
gall-bladder.  In  these  cases  auscultation  may  re- 
veal a  leather-like  creaking  over  the  gall-bladder, 
and  the  patient  may  have  a  distinct  sensation  of  the 
gall-bladder  being  pressed  against  the  abdominal 
wall,  or  of  an  inflated  stomach. 

As  regards  the  influence  of  the  taking  of  food 
upon  the  attacks  of  gall-bladder  colic,  we  may  say 
that  a  marked  contrast  exists  between  this  condition 
and  cases  of  pyloric  stenosis.  There  is  no  injury 
done  to  the  affected  parts  by  the  food,  as  is  the  case 
in  gastric  ulcer,  and  peristalsis  of  the  gall-ducts,  if 
at  all  excited  by  the  taking  of  food,  is  certainly  not 
so  deeply  influenced  as  is  intestinal  or  gastric  peri- 
stalsis. We  may  thus  say  that,  in  these  cases,  the 


DIGESTIVE   SYSTEM  215 

relation  of  the  taking  of  food  to  the  beginning  of 
an  attack  is  entirely  unimportant,  and,  as  a  matter 
of  fact,  this  is  true  in  all  those  cases  where  chole- 
lithiasis occurs  in  patients  of  otherwise  normal 
gastro-intestinal  tracts.  The  taking  of  food  is  im- 
portant in  relation  to  the  attacks  only  in  those  cases 
where  we  are  dealing  with  delicate,  anaemic  individ- 
uals, often  with  some  degree  of  enteroptosis,  espe- 
cially those  with  gastroptosis  and  general  atony  of 
the  stomach.  These  cases  are  chiefly  limited  to  the 
female  sex,  and  in  them  a  differential  diagnosis  be- 
tween a  gastric  condition  and  gall-bladder  colic  is 
extremely  difficult. 

It  is  not  at  all  out  of  the  question  that  in  some  of 
these  cases  following  an  error  in  diet,  a  gastralgia 
with  cramp-like  contractions  of  the  stomach  is 
started  which  may  secondarily  give  rise  to  an  attack 
of  colic  in  the  gall-ducts,  the  muscular  activity  of 
the  two  systems  being  functionally  so  closely  allied. 
The  influence  of  diet  upon  gall-duct  colic  is  similar 
in  many  ways  to  its  influence  upon  the  pains  of 
pyloric  stenosis,  and  it  is  not  at  all  unlikely 
that,  accompanying  some  cases  of  gall-stone,  there 
actually  does  occur  slight  obstruction  at  the  pylorus 
or  in  the  duodenum  itself.  On  the  one  hand,  gas- 
troptosis, which  is  so  often  present,  may  readily 
lead  to  kinking  of  the  duodenum  and  subsequent 
stenosis;  on  the  other,  it  is  not  infrequent  to  find 
adhesions  between  the  pylorus  and  the  gall-bladder 
which  may  cause  similar  obstruction. 

The  articles  of  diet  which  are  especially  apt  to  be 
responsible  for  the  attacks  are  all  those  which  lead 


216  PAIN 

to  distention,  vegetables,  carbohydrates,  bread,  etc.; 
also  fat,  meat,  cheese,  acid  food,  beer,  etc.  Attacks 
are  occasionally  inhibited  by  strong  alcohol  in  the 
form  of  brandy.  The  quality  of  the  food  is  often 
less  important  than  the  quantity,  in  that  the  attack 
is  initiated  simply  by  the  mechanical  overfilling  of 
the  stomach. 

Just  as  in  the  case  of  the  pain  accompanying 
ulceration  of  the  pylorus,  in  these  cases  the  position 
of  the  patient  has  an  important  influence  upon  the 
course  of  the  attacks.  The  pain  is  especially  severe 
when  the  patient  is  lying  on  his  left  side.  In  this 
position  he  may  complain  of  a  drawing  sensation 
which  gives  the  impression  of  something  being 
tugged  from  the  right  hypochondriac  region  toward 
the  left.  This  pain,  in  the  left-sided  position,  is 
especially  severe  whenever  there  is  great  flabbiness 
of  the  abdominal  walls,  and  therefore  corresponding 
mobility  of  the  abdominal  organs.  Mechanically  the 
explanation  is  extremely  simple  since,  in  this  posi- 
tion, the  swollen  organs  are  freely  suspended  from 
their  inflamed  peritoneal  attachments.  It  is  true 
that  in  some  cases  there  is  pain  also  in  the  right- 
sided  position,  and  this  is  easily  explained  by  the 
fact  that  greater  pressure  is  exerted  upon  the  liver 
and  gall-bladder ;  but  when  this  does  occur  the  pain 
is  not  accompanied  by  nausea  and  belching,  as  is 
almost  invariably  the  case  when  the  right-sided  pains 
occur  with  ulceration  and  stenosis  of  the  pylorus. 

Inflammatory  changes  in  the  neighborhood  of  the 
gall-bladder  and  in  the  serous  coverings  of  the  liver 


DIGESTIVE   SYSTEM  217 

give  rise  to  other  secondary  symptoms.  Thus  the 
jarring  accompanying  speech,  rapid  walking,  run- 
ning down  hill,  coughing  and  sneezing,  gives  much 
discomfort  during  the  attack  and  for  a  long  time 
afterwards.  Likewise  those  motions  are  very  pain- 
ful which  are  accompanied  by  pressure  upon  the 
abdominal  organs  in  general,  such  as  stooping,  put- 
ting on  the  shoes,  lifting  a  weight.  Bending  for- 
ward occasionally  causes  pain  in  the  back,  and  owing 
to  this  the  patients  often  instinctively  relax  their 
abdominal  muscles  by  walking  in  a  stooping  position 
or  shoving  a  pillow  under  their  backs. 

Like  the  stomach  and  intestine,  the  gall-bladder 
has  an  important  functional  dependence  upon  the 
central  nervous  system,  and  it  is  thus  not  surprising 
that  observations  have  been  made  which  would  indi- 
cate that  attacks  of  gall-stone  colic  have  been  initi- 
ated by  psychic  or  emotional  impulses. 

It  is  at  least  worth  considering  whether  such 
attacks  cannot  be  reflexly  initiated  from  other 
organs,  the  kidney,  the  genitals,  the  stomach,  or  the 
intestine,  either  in  th'e  presence  of  gall-stones  or 
with  any  other  lesion  of  the  bile  passages.  Abnor- 
mal irritability  of  the  nervous  system  may  certainly 
be  regarded  as  a  factor  favoring  the  attacks. 

There  is  a  very  definite  connection  between  gall- 
stone colic  and  conditions  of  obstruction  in  the 
alimentary  canal.  Thus,  prolonged  constipation 
may  occasionally  start  an  attack,  probably  by  pre- 
venting the  free  expulsion  of  bile,  and  occasionally 
an  attack  of  colic  may  be  interrupted  by  a  free  evacu- 


218  PAIN 

ation  of  the  bowels  by  enema  or  otherwise.  Such 
close  interrelation  is  logically  to  be  expected  when 
we  consider  the  close  functional  relationship  of  the 
gut  and  the  bile  passages. 

As  regards  the  time  of  attack,  there  is  unques- 
tionably a  greater  frequency  during  the  night  or 
evening,  but  this  is  not  striking  and  attacks  may 
occur  at  any  time  during  the  day. 

In  differentiating  gall-stone  colic  from  pyloric 
stenosis,  we  may  be  helped  by  remembering,  first, 
the  long,  free  intervals  occurring  between  attacks 
of  the  former  condition,  in  contrast  to  the  almost 
uninterrupted  suffering  of  the  latter.  When  attacks 
occur  daily  for  weeks  we  may  usually  conclude  that 
we  are  dealing  with  stones  which  are  immovably 
lodged  in  the  cystic  duct  or  with  one  of  those  cases 
of  enter opto sis  mentioned  above.  Stones  which  are 
situated  further  down,  in  the  less  narrow  common 
duct,  usually  give  rise  to  very  little  peristaltic  unrest 
in  the  gall-duct  system. 

The  most  important  of  the  secondary  symptoms 
which  are  to  be  considered  is  vomiting.  This  symp- 
tom especially  may  lead  to  confusion  in  pointing 
towards  a  gastric  condition,  such  as  ulceration  at  the 
pylorus;  but  the  character  of  the  vomiting  is  quite 
different  in  the  two  conditions.  In  the  case  of 
pyloric  ulceration  or  stenosis  the  vomiting  is  usually 
very  copious,  does  not  consist  of  bile,  has  a  sour 
taste,  and  is  usually  followed  by  immediate  relief 
from  pain ;  in  gall-stone  colic  it  is  usually  full  of  bile, 
is  bitter  in  its  taste,  and  in  most  cases  increases  the 


DIGESTIVE   SYSTEM  219 

pain  because  the  jarring  of  the  act,  as  well  as  the 
pressure  of  the  abdominal  muscles,  causes  consider- 
able pain  in  the  sensitive  liver  and  gall-bladder. 

If  the  physician  is  present  during  the  attack, 
examination  of  the  urine  will  quickly  determine 
whether  obstruction  of  bile  exists  or  not.  Such 
a  decision  is  much  more  difficult  when  we  have  to 
make,  up  our  minds  simply  by  means  of  the  state- 
ments of  the  patient.  We  must  not  lay  too  much 
weight  upon  the  patient's  statement  that  his  urine 
was  dark  during  the  attack,  for  in  the  attacks  of  the 
colic  of  gastric  ulcer  we  often  notice  the  excretion 
of  a  dark  concentrated  urine.  If  the  patient  is  able 
to  tell  us  that  the  urine  has  left  yellow  marks  upon 
the  linen  or  that  there  has  been  pruritus,  the  likeli- 
hood of  the  existence  of  true  icterus  becomes  very 
strong.  Jaundice  is  occasionally  absent  in  diseases 
of  the  liver  and,  on  the  other  hand,  is  often  present 
in  other  diseases,  chiefly  in  gastric  and  appendicular 
disease,  in  duodenal  ulcer  and  in  carcinoma  of  the 
hepatic  flexure ;  nevertheless,  when  icterus  has  never 
been  present  in  patients  whose  disease  has  existed 
for  a  considerable  period,  extreme  caution  must  be 
used  before  a  diagnosis  of  hepatic  disease  is  made. 

Shaking  chills  and  rises  of  temperature  are  fre- 
quently present  during  the  attacks  themselves,  but 
are  of  much  less  importance  than  increased  tempera- 
ture which  is  present  for  some  length  of  time  after 
the  attacks.  The  chills  and  rise  of  temperature  dur- 
ing the  attack  may  be  present  in  many  other  condi- 
tions in  persons  who  have  irritable  vasomotor  sys- 


220  PAIN 

terns.  The  temperature  which  occurs  after  attacks, 
however,  is  usually  an  expression  of  an  infection, 
such  as  that  which  is  frequently  present  in  gall- 
bladder colic,  and  is  therefore  of  much  more  impor- 
tance in  clearing  up  the  diagnosis.  Herpes  is  rarely 
present. 

The  symptoms  which  appear  on  physical  exam- 
ination are  chiefly  tumor  of  the  gall-bladder  and 
liver,  creaking  friction  sounds  over  the  gall-bladder, 
crepitant  rales  over  the  base  of  the  right  lung,  and 
occasionally  also  over  the  base  of  the  left  lung 
(splenic  enlargement). 

There  are  a  number  of  conditions  which  may 
simulate  gall-bladder  colic.  Chief  among  these  are : 

1.  Cicatricial  and  ulcerative  processes   of  the 
pylorus  (see  page  162). 

2.  Duodenal  Ulcer. — The  localization  of  the  at- 
tacks may  be  very  similar  in  the  two  conditions.    In 
a  general  way  the  same  distinguishing  characteris- 
tics may  be  drawn  between  these  two  conditions 
as  are  useful  in  differentiating  gall-bladder  colic 
from  pyloric  stenosis.    In  duodenal  ulcer  there  is 
almost  immediate  relief  after  vomiting  because  of 
the  evacuation  of  the  distended  stomach. 

3.  Appendicitis. — The  danger  of  false,  diagnosis 
is  especially  due  to  the  fact  that  many  cases  of 
cholelithiasis  show  tenderness  to  pressure  in  the 
ileocsecal  region ;  this  is  usually  caused  by  an  abnor- 
mal position  of  the  gall-bladder  on  account  of  a 
sinking  and  rotation  of  the  liver. 

In  a  great  many  cases  also  there  may  be  a  chronic 
inflammatory  process  of  the  appendix  directly  re- 


DIGESTIVE   SYSTEM  221 

lated  to  the  chronic  constipation  accompanying  gall- 
stone disease.  A  superficial  examiner  might  there- 
fore easily  misinterpret  attacks  of  colic  with  sensi- 
tiveness in  the  ileocaecal  region  as  appendicular  colic. 
On  the  other  hand,  cases  of  true  appendicitis  may 
simulate  gall-stone  colic  when  the  appendicular  pain 
is  situated  high  up,  because  of  an  abnormal  position 
of  the  appendix.  Careful  analysis  of  the  pains,  to- 
gether with  most  painstaking  examination  of  the 
liver  for  enlargement,  tenderness,  etc.,  can  alone 
give  us  clearness. 

4.  Carcinoma  of  the  Colon. — Another  condition 
which  it  is  difficult  to  differentiate  from  the  pain 
under  consideration  is  carcinoma  of  the  hepatic 
flexure  of  the  colon,  with  adhesions  to  the  gall-blad- 
der and  liver.  In  these  cases  there  are  colicky  at- 
tacks with  localization  and  radiation  similar  to  those 
of  true  gall-stone  colic.  Added  to  these,  slight 
jaundice  is  present,  due  to  adhesions  to  or  metas- 
tatic  infiltration  of  the  bile  passages.  The  difficulty 
may  be  further  increased  by  the  presence  of  a 
rounded  sensitive  tumor  which  cannot  be  separated 
from  the  liver. 

While  the  examination  of  the  feces  and  other 
subjective  signs  will  clearly  differentiate  these  con- 
ditions, the  writer  would  like  to  call  attention,  for 
the  purpose  of  rapid  diagnosis,  to  the  great  differ- 
ence which  exists  in  the  reaction  of  the  pains  of 
these  two  conditions  to  thermic  influences.  When- 
ever the  attacks  of  pain  are  easily  brought  on  by  the 
application  of  cold  (cold  drinks,  exposure  of  the 


222  PAIN 

abdomen,  etc.),  gall-duct  colic  is  extremely  unlikely, 
this  characteristic  being  peculiar  chiefly  to  the 
paroxysmal  pains  occurring  in  the  intestines. 

Eises  of  temperature  occur  in  ulcerating  carci- 
noma of  the  colon  and  therefore  give  us  no  differ- 
ential help.  However,  chills  at  the  time  of  the  attack 
would  point  more  particularly  to  gall-stone  colic. 
In  addition,  it  is  important  to  consider  the  con- 
stancy of  the  pain,  its  dependence  upon  dietetic 
influences,  its  relief  by  the  expulsion  of  flatus,  etc. 

As  far  as  objective  symptoms  are  concerned  the 
most  important  are  those  which  point  to  obstruction 
of  the  gut.  These,  of  course,  may  be  absent  for  a 
long  time.  Most  important  among  them  are  bor- 
borygmi  in  the  region  of  the  tumor  and  succussion 
sounds  along  the  ascending  colon;  it  must  not  be 
forgotten,  however,  that  even  disease  of  the  gall- 
bladder may  secondarily  lead  to  slight  obstruction 
in  the  region  of  the  hepatic  flexure. 

Diarrhoea  when  present  would  point  towards  an 
intestinal  origin  of  the  pains,  for  gall-duct  colic, 
especially  when  due  to  stone,  is  almost  always  accom- 
panied by  constipation. 

5.  Movable  Kidney. — Errors  are  very  easily 
made,  because  it  is  not  infrequent  that,  together  with 
an  irregular  cholelithiasis,  there  exists  a  movable 
kidney  which  is  assumed  to  be  the  cause  of  the  entire 
trouble.  This  combination  is  quite  usual,  and  there- 
fore errors  often  occur.  A  mistake  is  most  easily 
made  when  we  are  dealing  with  cases  of  chole- 
lithiasis which  run  their  course  with  constant  pain 


DIGESTIVE   SYSTEM  223 

in  the  epigastrium,  without  the  real  colicky  attacks 
and  without  icterus.  The  pain  in  these  cases  is 
influenced  by  jarring  and  motion,  and  it  is  not  at 
all  unlikely  that  when  the  kidney  is  movable  and  at 
the  same  time  gall-stones  are  present,  the  tugging 
of  the  loose  kidney  may  reflexly  lead  to  peristaltic 
unrest  in  the  bile-duct  system. 

If  the  colicky  pains  occur  while  the  body  is  in 
complete  rest,  for  instance,  during  sleep,  of  course 
the  assumption  of  movable  kidney  is  quite  out  of 
the  question. 

6.  Hysteria. — This  error  can  be  made  only  when 
the  existing  cholelithiasis  is  of  an  atypical  kind. 
Here  also  one  must  not  forget  that  the  conditions 
may  frequently  coincide.  Whenever,  of  course, 
purely  mechanical  methods,  such  as  the  position  of 
the  patient,  exert  an  influence  upon  the  pain,  we  can 
hardly  assume  that  the  condition  is  entirely  of  a 
functional  nature.  So,  too,  it  is  important  to  know 
whether  there  is  a  lack  of  harmony  between  the  gen- 
eral nervous  condition  and  the  severity  of  the  local 
pain,  for  with  an  improvement  in  the  general  ner- 
vous condition,  the  local  pains  in  the  epigastrium 
are  rather  more  likely  to  increase  than  to  decrease 
when  gall-stones  are  present.  General  rules  can- 
not be  made  for  cases  of  this  kind,  and  it  is  of  the 
greatest  importance  to  consider  carefully  the  in- 
dividuality of  the  patient  in  order  to  make  a  correct 
diagnosis.  When,  together  with  the  existence  of 
gall-stones,  severe  hysteria  is  present,  even  opera- 


224  PAIN 

tive  interference  will  not  always  guarantee  complete 
cessation  of  the  pains.  It  seems  that  in  these  cases 
we  must  consider  that  we  are  dealing  in  part  with 
a  visceral  neuralgia  (solar  plexus?  cf.  page  97), 
in  which  the  gall-bladder  pain  has  the  same  relation 
to  the  neuralgia  that  a  carious  tooth  would  have  to 
the  ordinary  trigeminal  neuralgia.  The  extraction 
of  the  tooth  might  bring  about  a  temporary  improve- 
ment, but  the  neuralgic  foundation  would  remain. 

It  is  an  open  question  whether  or  not  pure  neural- 
gia of  the  liver  may  exist  by  itself  without  organic 
foundation.  According  to  some  observers  such 
cases  may  occur  with  all  the  attributes  of  a  true  gall- 
stone colic,  except  fever  and  inflammatory  changes. 

7.  Syphilis  of  the  Liver. — Attacks  of  pain  may 
occur  in  the  train  of  rapidly  developing  liver  gum- 
mata,  the  causes  of  the  pain  being  sudden  tension 
of  the  liver  capsule  and  local  peritonitis.  The  con- 
fusion of  this  condition  with  gall-stone  colic  seems  to 
be  all  the  more  likely  because  these  cases  are  fol- 
lowed by  jaundice  and  increase  of  temperature,  and 
palpation  of  the  liver  reveals  enlargement  and  ten- 
derness. However,  more  careful  examination  will 
frequently  show  unevenness  of  the  liver  surface, 
and,  on  the  other  hand,  syphilitic  processes  occur 
frequently  in  the  left  lobe  of  the  liver;  thus 
there  may  be  a  peculiar  left-sided  localization  of  the 
pains,  a  localization  which  hardly  ever  occurs  in  gall- 
stone colic.  In  every  difficult  case  the  prompt  im- 
provement under  iodides  may  be  decisive.  Similar 


DIGESTIVE   SYSTEM  225 

symptoms  may  occur  with  primary  or  secondary  car- 
cinoma of  the  liver. 

In  our  introduction  we  have  already  called  atten- 
tion to  the  fact  that  while  gall-bladder  colic  is  usually 
caused  ,by  the  existence  of  gall-stones,  there  may 
nevertheless  exist  cases  of  true  gall-bladder  colic 
without  the  presence  of  gall-stones.  These  cases, 
as  it  was  pointed  out,  are  chiefly  dependent  upon 
inflammatory  stenoses  along  the  bile  ducts. 

The  occasional  combination  of  a  gall-stone  colic 
with  haematemesis  and  melaena  would  lead  us  to 
think  of  aneurysm  of  the  hepatic  artery.  Likewise 
we  would  have  to  consider  ulcerative-stenotic  condi- 
tions at  the  papilla  of  Vater. 

In  patients  who  are  suffering  from  marked  en- 
teroptosis  mild  attacks  of  such  colicky  pains  would 
suggest  kinking  along  the  cystic  duct.  When  other 
symptoms  point  to  biliary  cirrhosis  the  possibility 
of  an  inflammatory  colic  of  the  gall-ducts  must  be 
thought  of. 

It  is  a  point  of  practical  importance  that  in  pa- 
tients who  have  their  first  attack  of  gall-stone  colic 
at  an  advanced  age,  or  in  those  in  whom  such  attacks 
are  repeated  only  after  prolonged  intervals,  we  may 
be  dealing  not  with  gall-stones  but  with  a  developing 
carcinoma  of  the  gall-bladder,  or  possibly  with  both 
conditions  together.  An  early  operation  for  carci- 
noma of  the  gall-bladder  is  made  possible  only  on  the 
basis  of  the  subjective  phenomena,  and  even  then 
only  upon  a  diagnosis  of  probability. 
15 


226  PAIN 

Gall-bladder  Pains  without  Attacks  of  Colic. 

In  all  the  preceding  conditions  we  have  spoken 
of  attacks  of  colicky  pain  which  are  probably  caused 
by  the  more  or  less  sudden  increase  of  intravesical 
pressure  or  by  tonic  contractions  along  the  muscu- 
lature of  the  bile  ducts. 

There  are  still  those  cases  to  be  considered  in 
which  the  same  etiological  factors  may  give  rise-  to 
more  gradual  pathological  changes,  and  therefore 
express  themselves  in  more  constant  local  pains  over 
the  gall-bladder  rather  than  in  paroxysmal  attacks. 
Here,  too,  we  must  consider  stenotic  processes  which 
lead  to  an  overdistention  of  the  gall-bladder.  The 
chief  conditions  which  must  be  thought  of  in  this 
connection  are  diseases  of  the  pancreas  of  an  inflam- 
matory or  malignant  nature,  and  inflammatory  proc- 
esses of  the  gall-bladder  itself,  either  of  a  local 
nature  (gall-stones,  typhoid)  or  of  an  ascending 
nature  (duodenal  catarrh,  cholangeitis,  biliary  cir- 
rhosis). Added  to  these  conditions  there  frequently 
occur  inflammatory  changes  in  the  peritoneal  cover- 
ings of  the  organ,  a  pericholecystitis ;  and  this  gives 
us  a  third  factor  which,  together  with  the  distention 
and  the  muscular  contractions,  adds  to  the  general 
picture  of  gall-bladder  pains.  Such  lesions  are  for 
many  reasons  extremely  unsatisfactory  for  physical 
examination,  and  the  subjective  pains,  therefore, 
assume  especial  diagnostic  importance. 

Generally  the  pains  are  localized  in  the  gall- 
bladder region  itself;  in  cases  of  enteroptosis  or 
corset  liver  the  pains  may  be  close  to  the  ileocaecal 
region. 


DIGESTIVE  SYSTEM  227 

The  peculiarities  of  the  pains  which  can  be  pro- 
duced by  physical  examination  have  already  been 
spoken  of  in  the  section  on  gall-bladder  colic. 
Sharply  localized,  stabbing  pains  in  the  gall-bladder 
region  may  be  caused  by  percussion  in  the  right  loin, 
by  coughing,  by  sneezing,  and  by  the  pressure  ex- 
erted in  strong  contraction  of  the  abdominal  muscles 
such  as  vomiting,  straining  at  stool,  and  rising  from 
a  horizontal  position.  Deep  respiration  causes  pain 
over  the  gall-bladder,  especially  in  those  cases  where 
pericholecystic  complications  exist.  Spontaneous 
pain  is  very  slight  in  many  cases ;  and  often  the  fact 
that  there  is  localized  pain  in  the  gall-bladder  region 
is  brought  out  only  by  one  of  the  methods  just 
described. 

Similar  sensations  might  occasionally  be  caused 
by  an  abnormally  movable  right  kidney.  Findings 
of  such  a  nature,  of  course,  cannot  be  decisive, 
since  gall-bladder  disease  is  frequently  coexistent 
with  movable  kidney.  It  would  be  much  more  im- 
portant to  find  an  enlarged  gall-bladder.  Increase 
of  the  temperature  (cholecystitis)  and  persistence 
of  the  pain  during  the  prone  position  would  point 
towards  the  gall-bladder  as  the  origin  of  the  pains. 

Pains  due  to  flatulence,  which  so  frequently  occur 
with  atony  of  the  gut,  as  in  chronic  nicotine  poison- 
ing and  neurasthenia,  are  occasionally  localized  over 
the  gall-bladder  region  (hepatic  flexure),  but  can  be 
easily  distinguished  from  gall-bladder  disease  by 
the  fact  that  they  vary  in  their  localization. 


228  PAIN 

II.  and  III.  Distention  and  Inflammation  of  the 
Capsule  of  the  Liver. 

Up  to  the  present  time  we  have  spoken  only  of 
liver  pains  which  have  their  seat  in  the  biliary  sys- 
tem, and  its  appendix,  the  gall-bladder.  Here  we 
had  in  addition  to  the  factor  of  distention  the  cramp- 
like  peristalsis  of  the  muscular  elements.  In  the 
following  paragraphs  we  will  deal  with  conditions 
localized  in  the  peritoneal  coverings  of  the  liver. 
In  these,  pains  are  caused  both  by  distention,  when 
the  liver  is  enlarged,  and  by  inflammatory  processes 
about  the  liver  (perihepatitis). 

It  is  more  practical  and  useful  not  to  separate 
these  two  varieties  of  pain,  since,  although  they  are 
distinct  etiologically,  they  very  frequently  occur 
together. 

(a)  Hcematogenous  Congestion  of  the  Liver. — 
Such  cases  are  usually  caused  by  cardiac  lesions, 
especially  by  insufficiency  of  the  right  heart.  Never- 
theless occasionally  extracardial  causes  must  be  con- 
sidered, such  as  narrowing  of  the  inferior  vena  cava 
by  aneurysms,  thrombi,  fibrous  changes  of  the  peri- 
cardium, fluid  exudate  in  the  right  pleura,  right 
pneumothorax,  and  narrowing  of  the  hepatic  veins 
through  perihepatitis. 

Next  to  the  regularly  present  enlargement  of  the 
organ  the  most  constant  symptom  of  these  anomalies 
of  the  circulation,  at  least  in  their  acute  and  sub- 
acute  stages,  is  the  characteristic  pain.  There  can 
hardly  be  any  reason  for  doubting  that  the  mechan- 
ism of  the  pains  in  these  cases  depends  upon  the 


DIGESTIVE   SYSTEM  229 

stretching  of  the  liver  capsule.  The  quality  of  these 
pains  is  almost  always  that  of  a  feeling  of  pressure 
in  the  epigastrium  which  varies  in  degree  from,  sim- 
ple discomfort  to  actual  pain,  so  that  the  patients 
speak  often  of  ' '  stomach-ache. ' '  Radiations  do  not 
occur  in  this  kind  of  pain.  The  patient  frequently 
feels  as  though  there  were  a  constant  and  heavy- 
weight upon  the  stomach. 

The  most  characteristic  quality  by  which  this 
species  of  pain  can  be  recognized  is  the  increase  in 
its  severity  which  occurs  whenever  more  work  is 
laid  upon  the  heart.  This,  of  course,  is  natural  in 
that  it  increases  the  actual  cause  of  the  pain.  The 
patient  who  is  suffering  from  a  congested  liver  com- 
plains of  an  increase  of  the  pain  when  he  walks  up- 
stairs, whereas  it  is  very  much  less  marked  when  he 
is  walking  downstairs.  Struggling  against  the  wind, 
running,  in  short,  every  physical  exertion  increase 
the  suffering. 

Percussion  of  the  liver  is  painful,  and  it  is  not 
surprising  that  in  the  face  of  the  diffuse  and  even 
stretching  of  the  liver-capsule  the  pain,  on  percus- 
sion, should  have  an  analogously  diffuse  and  even 
distribution.  As  a  matter  of  fact,  however,  the 
maximum  pain  is  felt  in  percussion  along  the  linea 
alba  and  extends  in  this  line  from  the  tip  of  the 
ensiform  down  to  the  liver  margin.  This  close  cor- 
respondence of  the  zone  of  greatest  pain  with  the 
liver  dullness  in  the  line  of  the  linea  alba  is  particu- 
larly important  in  differentiating  this  condition  from 
other  epigastric  pains.  For  this  reason  examina- 


230  PAIN 

tion  by  percussion  is  more  important  in  this  condi- 
tion than  examination  by  palpation. 

The  explanation  of  the  fact  that  in  spite  of  the 
diffuse  nature  of  the  process  the  maximum  pain,  on 
percussion,  extends  along  the  linea  alba  probably 
lies  in  the  circumstance  that  here  the  muscular  de- 
fense is  least  effectual,  especially  in  cases  where 
there  is  some  separation  of  the  recti.  Probably  the 
same  explanation  holds  good  for  a  similar  localiza- 
tion of  the  greatest  tenderness  along  the  linea  alba 
in  gastric  ulcer. 

Whenever,  therefore,  one  wishes  to  examine  for 
pain  in  cases  suspicious  of  hepatic  congestion,  it  is 
advisable  to  percuss  along  the  linea  alba. 

If  cases  dependent  upon  uncompensated  cardiac 
lesions  are  examined  in  this  way  while  they  are 
under  treatment  with  digitalis,  it  is  often  possible 
to  notice  that  the  pain  will  diminish  from  day  to 
day  if  approximately  the  same  force-  of  percussion 
is  used.  In  this  way  we  have  a  very  simple  means 
of  controlling  the  processes  of  compensation  of  the 
right  heart.  At  the  same  time  the  influence  exerted 
by  the  therapy  upon  the  tenderness  throws  definite 
light  upon  the  etiology  of  the  condition. 

The  position  of  the  body  has  a  definite  influence 
upon  the  intensity  of  the  suffering.  The  upright 
position  naturally  leads  to  a  greater  stagnation  of 
blood  in  the  liver,  while  the  horizontal  position 
allows  of  a  better  outflow  of  blood. 

Dietetic  conditions  also  may  have  a  definite  effect 
upon  the  hyperaemia  of  the  liver  and  therefore  upon 
the  pains  (spices,  large  quantities  of  meat,  etc.). 


DIGESTIVE   SYSTEM  231 

Occasionally  mechanical  and  dietetic  conditions 
may  be  combined  (bodily  exertion  immediately  after 
meals). 

The  physical  signs  accompanying  increase  of  the 
pain  are  chiefly  enlargement  and  firmer  consistency 
of  the  organ.  The  latter  condition  is  frequently 
noticed  by  the  patient  himself,  who  may  observe 
a  diffuse  firmness  in  the  epigastrium  after  exertion. 

In  many  cases,  of  course,  the  congestion  of  the 
liver  is  merely  a  secondary  factor  in  the  general 
clinical  picture,  and  it  may  be  easy  to  explain  the 
enlargement  of  the  organ  without  paying  much  at- 
tention to  the  character  and  quality  of  the  pains. 
The  enlargement  of  the  liver  falls  in  naturally  with 
the  cyanosis  and  the  redema.  On  the  other  hand, 
there  are  cases  in  which  the  hepatic  congestion  and 
the  suffering  resulting  from  it  may  be  predominant. 

The  cases  chiefly  to  be  considered  in  this  con- 
nection are  especially  those  of  acute  pericarditis, 
which  are  frequently  characterized  by  epigastric 
rather  than  by  cardiac  symptoms ;  and  these  epigas- 
tric symptoms,  on  closer  analysis,  can  be  recognized 
as  being  due  to.  hepatic  congestion.  The  same  is 
true  of  the-  symptoms  accompanying  many  cases  of 
adherent  pericardium,  and  in  these  often  the  diag- 
nosis of  hepatic  congestion  can  be  made  before  the 
condition  of  the  heart  is  recognized. 

Again  there  are  cases  in  which,  even  when  the 
signs  of  an  insufficiency  of  the  right  ventricle  are 
perfectly  clear,  there-  may  be.  much  doubt  as  to 
whether  the  existing  enlargement  of  the  liver  is  to 


232  PAIN 

be  explained  by  simple  congestion,  or  whether  other 
pathological  processes,  for  instance  cirrhosis,  may 
have  a  part  in  it.  In  just  these  cases  the  examina- 
tion of  the  organ  for  its  sensitiveness  and  the  zones 
of  distribution  of  these  pains,  as  determined  by 
physical  examination,  may  lend  invaluable  aid. 

The  pathological  basis  of  the  pain  of  congestion 
lies  in  the  acute  or  subacute  distention  of  the  organ 
and  its  peritoneal  coverings.  This,  however,  pre- 
supposes the  possibility  of  distending  the  organ 
itself.  In  cases  where  there  has  been  much  forma- 
tion of  fibrous  tissue,  as  in  cirrhosis,  distention  is 
not  possible,  and  even  an  acute  cardiac  insufficiency 
is  unable  to  produce  any  marked  degree  of  pain. 
Therefore,  whenever  acute  general  congestion  ex- 
ists without  any  marked  degree  of  pain  in  the  liver, 
we  must  always  be  suspicious  of  a  preexisting  cir- 
rhosis. It  is  well,  however,  to  be  cautious  in  those 
cases  where  the  cardiac  lesion  has  developed  in  very 
chronic  stages  and  has  carried  in  its  train  a  consid- 
erable degree  of  connective  tissue  formation  (car- 
diac cirrhosis). 

Occasionally  inflammatory  factors,  such  as  acute 
perihepatitis,  may  contribute  to  the  production  of 
the  pain.  Such  complications  are  characterized  by 
a  sudden  increase  in  the  subjective  pain  without 
a  corresponding  exacerbation  of  the  cardiac  condi- 
tion. In  contradistinction  to  the  dull,  aching  pres- 
sure produced  by  stretching  of  the  capsule,  this  pain 
is  acute  and  stabbing,  and  because  of  its  peritoneal 
and  inflammatory  nature  it  is  increased  upon  deep 


DIGESTIVE  SYSTEM  233 

respiration  (rubbing  of  peritoneal  surfaces).  This 
pain  is  independent  of  digitalis  treatment,  but  on 
the  other  hand  is  rapidly  and  effectually  controlled 
by  local  treatment.  "When  perihepatitis  is  present 
it  is  almost  impossible  to  lie  upon  the  painful  side. 
Friction  sounds  accompany  the  pains  only  when 
there  is  a  fibrinous  exudation  of  considerable  quan- 
tity and  the  fibrinous  masses  are  of  favorable  con- 
sistency. 

Further  details  of  the  pains  accompanying  peri- 
hepatitis  will  be  discussed  when  speaking  of  syphilis 
of  the  liver. 

(b)  Biliary  Congestion. — In  the  same  way  that 
an  overfilling  of  the  blood  vessels  may  lead,  by  a 
secondary  stretching  of  the  capsule,  to  liver  pains, 
so  the  condition  of  congestion  in  the  bile  ducts  may 
give  rise  to  a  very  similar  state  of  affairs.  The 
suffering  produced  by  biliary  congestion,  however, 
rarely  equals  in  intensity  that  produced  by  conges- 
tion in  the  blood  vessels,  largely  because  of  the 
differences  of  pressure  in  the  two  conditions. 
Nevertheless  pain  over  the  liver  upon  percussion 
along  the  linea  alba  is  not  uncommon  in  those  dis- 
eases which  are  accompanied  by  congestion  of  bile 
(catarrhal  jaundice,  Hanot's  cirrhosis,  carcinoma  of 
the  head  of  the  pancreas,  etc.). 

These  conditions  are  also  accompanied  by  the 
gall-bladder  pains  which  we  have  mentioned  above, 
which  occur  without  true  colicky  attacks.  These 
may  exist  in  varying  degrees,  from  the  simple  sensa- 
tion of  pressure  to  conditions  approaching  gall- 


234  PAIN 

bladder  colic.  It  is  therefore  always  important  to 
percuss  along  the  linea  alba  as  well  as  over  the  gall- 
bladder itself. 

Since  stagnation  of  the  bile  is  often  directly  the 
result  of  inflammation  of  the  mucous  membrane  of 
the  passages,  and  since,  on  the  other  hand,  biliary 
congestion  favors  inflammation  of  these  passages, 
it  is  not  surprising  that  these  conditions  are  fre- 
quently accompanied  by  perihepatitis  and  the  pains 
characteristic  of  this  condition.  Therefore  the  pa- 
tient who  is  suffering  from  Hanot's  cirrhosis  often 
complains  of  a  sharp  pain  along  the  right  costal 
margin  or  in  the  region  of  the  right  hypochondrium. 
This  pain  is  often  dependent  upon  movements  which 
cause  peritoneal  friction,  such  as  running,  coughing, 
sneezing,  or  deep  respiration.  Sometimes,  though 
rarely,  it  radiates  towards  the  right  shoulder. 
Such  variation  is  entirely  consistent  with  its  sub- 
diaphragmatic  position.  The  pains  which  occur  in 
the  back  and  are  increased  by  stooping  must  be 
explained  by  the  distention  of  the  liver  capsule. 

We  have  already  mentioned  that  gall-bladder 
colic  may,  though  rarely,  be  part  of  the  clinical 
picture  of  a  Hanot's  cirrhosis. 

Tenderness  on  percussion  over  the  liver,  along 
the  linea  alba  and  over  the  gall-bladder  as  well,  is 
occasionally  found  in  cases  of  catarrhal  jaundice, 
and  is  directly  proportionate  to  the  degree  of  biliary 
congestion. 

In  cases  where  the  inflammatory  processes  are 
not  limited  to  the  larger  passages  alone  but  extend 


DIGESTIVE   SYSTEM  235 

into  the  bile  capillaries,  extension  takes  place  into 
the  peritoneal  coverings,  and  thus  a  new  reason 
for  tenderness  is  added.  Therefore,  whenever  the 
pain  is  extremely  acute  without  great  enlargement 
of  the  organ,  it  is  logical  to  think  of  an  inflamma- 
tory perihepatitis.  In  such  cases  also  the  gall- 
bladder becomes  involved  and  there  is  local  tender- 
ness to  palpation  and  percussion,  and  local  pain  in 
the  gall-bladder  region  upon  jarring  of  the  body. 
"When  this  occurs  it  is  important  to  think  of  the  pos- 
sibility of  preexisting  lesions  in  the  gall-bladder, 
such  as  gall-stones,  since  ordinarily  the  gall-bladder 
pains  are  not  an  accompaniment  of  catarrhal  icterus. 

In  considering  conditions  which  lead  to  abnormal 
stretching  of  the  liver  capsule,  special  attention  is 
due  to  the  cystic  new  growths  of  the  liver,  and  par- 
ticularly to  the  development  of  echinococcus  cysts. 
The  pains  which  occur  in  this  condition  remind  us  in 
many  of  their  peculiarities  of  the  phenomena  con- 
sidered under  the  heading  of  gall-bladder  colic. 

In  rare  instances  the  passage  of  small  cysts 
through  the  bile  ducts  may  give  rise  to  attacks  of 
pain.  More  frequently,  however,  pains  in  this  con- 
dition are  due  to  pressure  and  consequent  stenosis 
of  the  gall-ducts.  Likewise,  sudden  changes  in  vol- 
ume of  the  echinococcus  cysts  frequently  occur,  and 
these  give  rise  to  inflammatory  swelling  of  the  liver 
tissue  surrounding  the  growth.  The  attacks  of  pain, 
which  often  occur  suddenly,  are  usually  localized 
in  the  right  hypochondrium  under  the  right  costal 
border,  and  radiate  towards  the  right  shoulder  blade 


236  PAIN 

and  the  sternum.  The  pain  may  also  begin  in  the 
back  and  radiate  forward  on  both  sides;  more  or 
less  constant  pain  in  both  scapulae  and  in  the  back 
may  be  present. 

The  similarity  to  gall-stone  colic  may  be  accen- 
tuated by  the  occurrence  of  nocturnal  attacks.  The 
attacks  may  be  colicky,  often  severe  enough  to  cause 
syncope ;  again  they  may  be  of  a  more  constant  dull 
character.  Mechanical  factors  materially  influence 
the  pains.  Thus  the  pain  is  often  at  its  maximum 
when  the  patient  lies  on  the  left  side,  and  in  this 
position  has  a  sensation  of  a  heavy  mass  being 
dragged  from  right  to  left.  Jarring  of  the  body 
increases  the  pain.  Thus  sneezing,  coughing,  per- 
cussion upon  the  right  loin,  or  any  exertion  causes 
pain.  Motions  which  are  dependent  upon  contrac- 
tion of  the  abdominal  musculature,  bending,  lifting, 
etc.,  lead  to  stabbing  sensations  over  the  liver.  The 
echinococcus  cyst  itself  is  sensitive  in  but  few  of  the 
cases.  Accompanying  the  attacks  of  pain,  syncope 
may  occur ;  sensations  of  suffocation  and  rise  of  tem- 
perature are  not  rare.  Singultus  may  occur  and 
give  a  clue  to  the  subdiaphragmatic  nature  of  the 
condition.  Great  attention  must  be  paid  to  those 
symptoms  which  emanate  from  the  stomach  and 
often  lead  to  an  erroneous  diagnosis  of  gastric 
disease.  These  are  due  in  most  cases  to  the  crowd- 
ing of  the  stomach  by  the  cystic  sac,  which  produces 
the  symptoms  of  slight  obstruction  and  gastric  peri- 
stalsis. This  error  can  be  well  guarded  against 
if,  on  principle,  in  all  cases  of  apparent  gastric  dis- 


DIGESTIVE   SYSTEM  237 

ease,  we  examine  the  liver  and  the  spleen  as  well 
as  the  stomach. 

The   statements   made   in   regard   to   the  pain 
accompanying  distention  of  the  liver  capsule  are 
hard  to  reconcile  with  those  cases  of  carcinomatous 
infiltration  of  the  liver  which  are  unaccompanied 
by  pain,  even  when  the  liver  is  enormously  enlarged. 
The  same  is  true  of  most  cases  of  fatty  or  hyalin 
infiltration  of  the  liver.     The  strange  behavior  of 
these  diseases  is  probably  explained  by  the  more 
gradual  enlargement  which  the  liver  undergoes.    In 
carcinoma.,  especially,  the  liver  is  not  enlarged  in 
toto  but  in  different  places  at  different  times,  so  that 
the  peritoneal  coverings  have   an  opportunity  to 
adjust  themselves  to  the  changed  conditions.    If  car- 
cinoma of  the  liver  is  accompanied  by  pains  at  all, 
they  are  usually  traceable  directly  to  stenosis  along 
the  bile-ducts  (carcinoma  of  the  pancreas  or  the  bile- 
ducts)   or  to'  the  perihepatitis.     Occasionally,  too, 
carcinoma  of  the  liver  may  be  complicated  by  gall- 
stones, which  then  would  account  for  the  pain.     The 
sharp  pains  which  indicate  perihepatitis  seem  to  be 
associated  chiefly  with  secondary  carcinoma  of  the 
liver,  especially  when  the  primary  growth  is  an  ulcer- 
ating neoplasm  of  the  gastro-intestinal  tract.    It 
stands  to  reason  that  in  such  cases  the  conditions  are 
favorable  for  secondary  inflammatory  processes.    In 
cases  of  this  kind  occasionally  sharp  and  prolonged 
attacks  of  pain  occur,  and  these  are  dependent  upon 
all  those  motions  which  give  rise  to  peritoneal  fric- 
tion, thus  pointing  to  the  peritoneal  cause  of  the 


238  PAIN 

suffering.  Pain  is  caused  especially  by  those  carci- 
nomatous  nodules  which  lie  subperitoneally  and 
secondarily  involve  the  peritoneum. 

There  are  many  cases  in  which  it  is  important  to 
determine  whether,  with  the  existence  of  a  gastric 
carcinoma,  the  liver  has  already  been  involved  or 
not.  In  these  we  are  forced  to  pay  particular  atten- 
tion to  the  existence  of  pain  in  the  right  hypochon- 
drium,  since  it  is  hardly  ever  possible  to  discover 
by  physical  examination  carcinomatous  nodules  sit- 
uated under  the  dome  of  the  diaphragm;  the  same 
applies  to  circumscribed  tenderness  over  the  palpa- 
ble liver  surface.  Acute  and  paroxysmal  attacks  of 
pain  of  a  moderate  colicky  nature  are  characteristic 
chiefly  of  neoplasms  which  have  caused  stenosis  of 
the  bile  passages.  Chief  among  these  are  the  neo- 
plasms situated  in  the  pancreas. 

Carcinoma  of  the  gall-ducts  occasionally  runs  its 
course  without  either  subjective  or  objective  pain. 
Local  pain  involving  the  gall-bladder  and  in  part  the 
right  lobe  of  the  liver  accompanies  all  those  cases, 
however,  in  which  inflammatory  changes  have  taken 
place  within  or  about  the  gall-bladder.  In  these 
cases,  too,  mild  attacks  of  gall-bladder  colic  may 
occur  even  without  the  existence  of  a  gall-stone. 

The  fact  that  the  left-sided  position  is  particu- 
larly painful  in  many  cases  of  carcinomatous  en- 
largement of  the  liver  is  explained  upon  purely  me- 
chanical grounds.  In  this  position  the  heavy  organ 
drops  towards  the  left  side  and  the  patient  feels 
a  drawing  pain  which  extends  from  right  to  left.  If 


DIGESTIVE   SYSTEM  239 

the  capsule  of  the  liver  is  inflamed  this  change  of 
position  of  the  liver  gives  rise  to  extreme  pain,  and, 
in  such  cases,  the  patient  voluntarily  prefers  to  lie 
flat  upon  his  back;  thus  immobilizing  the  organ. 
Very  frequently  stooping  gives  rise  to  great  pain 
in  the  back. 

Attacks  of  pain  of  intestinal  origin  are  not  rare 
in  carcinoma  of  the  liver.  These  are  due,  on  the 
one  hand,  to  direct  infiltration  of  the  colon  from  the 
gall-bladder  and  consequent  moderate  obstruction. 
On  the  other  hand,  there  frequently  exists  a  tendency 
to  meteorism  which  leads,  by  a  local  collection  of 
flatus,  to  attacks  of  a  colicky  nature.  These  attacks 
are  easily  controlled  by  emptying  the  bowels. 

Much  more  marked  than  in  carcinoma  of  the  liver 
are  the  pains  which  accompany  liver  gummata,  and 
these  are  so  regular  that  in  all  cases  where  pains 
occur  in  the  liver  region  it  is  necessary  to  think  of 
this  possibility. 

A  local  perihepatitis  is  almost  regularly  present 
because  of  the  inflammatory  nature  of  the  new 
growth,  and  in  this  secondary  phenomenon  lies  the 
causes  of  the  pain.  This  is  made  particularly  evi- 
dent by  the  factors  which  influence  the  pain.  Pain 
is  initiated  or  increased  by  deep  respiration,  by 
rapid  walking,  by  jarring  of  the  body,  by  walking 
downstairs,  by  slipping  of  the  right  foot,  and  by 
laughing  or  coughing. 

Just  as  direct  pressure  upon  the  painful  area 
increases  the  pain,  so  motions  which  indirectly  give 
rise  to  greater  pressure  increase  it  as  well.  Occa- 


240  PAIN 

sionally,  too,  the  taking  of  food  will  cause  increased 
suffering  (perihepatic  adhesions). 

A  great  deal  of  differential  knowledge  may  be 
gained  by  the  therapy.  The  pains  are  almost  imme- 
diately relieved  by  iodides  and  (in  one  of  the 
author's  cases)  by  arsenic.  If  the  pains  are  situ- 
ated on  the  right  side  under  the  costal  margin,  there 
is  radiation  into  the  right  shoulder  blade  and  into 
the  back.  If  the  pain,  in  addition  to  this  radiation, 
assumes  the  nature  of  a  colicky  attack  and  is  accom- 
panied by  vomiting,  slight  fever,  and  icterus,  the 
danger  of  confusing  it  with  gall-bladder  colic  is 
plain.  Here  only  an  exact  physical  examination  can 
make  the  differentiation,  by  revealing  a  circum- 
scribed tumor  upon  the  liver  surface.  Very  fre- 
quently, however,  the  pains  are  situated  along  the 
left  costal  margin,  because  of  the  frequent  involve- 
ment of  the  left  lobe  of  the  liver.  They  are  then 
more  constant  in  their  nature,  without  colicky  at- 
tacks. They  may  be  sharp  or  dull  without  giving 
rise  to  radiation,  and  tenderness  over  the  gall- 
bladder region  may  be  entirely  absent. 

In  contradistinction  to  echinococcus,  in  the  syphi- 
litic condition  the  tumor  itself  is  markedly  sensitive. 

PANCREAS. 

In  this  organ,  in  which  we  have  neither  the 
mechanism  of  muscular  contraction  nor  the  intimate 
relation  to  the  peritoneum  found  in  the  liver,  there 
would  seem  to  be  very  little  basis  for  the  develop- 
ment of  characteristic  pains.  On  the  other  hand, 


DIGESTIVE   SYSTEM  241 

experience  tells  us  that  certain  lesions  of  the  pan- 
creas are  accompanied  regularly  by  attacks  of  pecu- 
liarly intense  pain.  The  most  important  among 
such  lesions  are  pancreatic  cysts. 

In  accounting  for  this  it  is  of  primary  impor- 
tance to  consider  the  intimate  relations  which  the 
pancreas  holds  to  the  nervous  system  in  general 
and  to  the  solar  plexus  in  particular ;  and  it  is  quite 
likely  that,  occasionally,  we  are  confronted  with 
purely  neuralgic  conditions.  This,  however,  does 
not  exclude  the  possibility  that  occasionally  pains 
may  be  produced  in  the  pancreas  by  exactly  the  same 
mechanism  by  which  they  are  produced  in  the  liver ; 
that  is,  by  cramp-like  contractions  and  increased 
pressure  in  the  excretory  ducts.  Because  of  the 
disproportionate  structure  of  the  muscular  appa- 
ratus of  these  ducts,  however,  it  is  hardly  possible 
to  explain  in  this  way  any  of  the  very  intense 
paroxysmal  attacks. 

Again,  it  is  quite  easy  to  understand  that  many 
of  the  pains  occurring  with  pancreatic  lesions  may 
emanate  from  neighboring  organs,  rather  than  from 
the  pancreas  itself. 

In  this  connection  the  very  intimate  topographi- 
cal relation  of  the  terminal  end  of  the  ductus  chole- 
dochus  to  the  head  of  the  pancreas  is  important; 
the  close  apposition  of  these  two  structures  makes 
it  self-evident  that  any  pathological  changes  in  the 
head  of  the  pancreas  would  lead  to  compression  of 
the  common  bile  duct;  and  this,  of  course,  would 
lead  to  stenosis  with  consequent  colicky  attacks  in 
the  gall-ducts. 

16 


242  PAIN 

We  must  remember,  however,  that  frequently 
diseases  of  the  gall-passages  and  of  the  pancreas 
may  be  present  at  the  same  time.  In  cysts  of  the 
pancreas,  the  pancreatic  nature  of  the  disease  may 
be  particularly  obscured  by  pressure  upon  portions 
of  the  gut,  giving  rise  to  paresis,  peritonitis,  and 
their  consequent  train  of  symptoms.  Because  of  the 
very  intimate  relationship  of  vascular  disease  to  the 
general  pathology  of  the  pancreas,  we  must  occa- 
sionally think  of  pains  arising  in  the  vessels. 

From  these  considerations  it  naturally  becomes 
clear  that  any  attempt  to  separate  purely  local  pan- 
creatic pains  from  those  depending  upon  the  neigh- 
boring organs  must  be  extremely  difficult. 

The  law  which  states,  in  a  general  way,  that 
organ  pains  correspond  in  localization  to  the  organ 
from  which  they  emanate,  is  borne  out  by  pancreatic 
conditions.  So,  because  of  the  chiefly  left-sided  posi- 
tion of  the  pancreas,  the  pains  which  arise  in  it  are 
situated  in  the  left  half  of  the  epigastrium,  to  the 
left  of  the  umbilicus,  or  even  in  the  left  loin.  Occa- 
sionally with  these,  radiations  may  be  observed 
which  are  symmetrical  with  'Lliose  occurring  in  gall- 
bladder colic. 

It  has  been  mentioned  above  that  occasionally 
the  colic  accomparying  pyloric  stenosis  may  behave 
in  the  same  way.  This  left-sided  character  of  the 
pain  in  pancreatic  lesions,  therefore,  might  under 
certain  conditions  be  of  gastric  origin,  in  that  the 
pathological  changes  in  the  pancreas  have  second- 
arily produced  a  pyloric  stenosis  by  compression 


DIGESTIVE   SYSTEM  243 

and  spasm.  At  all  events  it  is  necessary  to  pay  very 
close  attention  to  the  presence  of  gastric  distention, 
peristalsis,  or  sarcinae  in  the  vomitus  or  feces. 

It  is  easy  to  understand  that,  corresponding  with 
the  retroperitoneal  position  of  the  organ,  pains  in 
the  back  should  frequently  occur.  These  pains 
sometimes  radiate  forward  and  around  the  waist. 
Sensitiveness  to  pain  will  change  in  its  localization 
according  to  the  position  of  the  lesion  in  the  pan- 
creas. Since  it  is  necessary,  in  palpating,  to  exert 
deep  pressure  towards  the  vertebral  column,  the 
localization  of  the  tenderness  is  of  little  diagnostic 
value.  It  is  important  also  to  look  for  sensitiveness 
to  pressure  and  percussion  along  the  upper  lumbar 
vertebrae,  a  symptom  which  I  have  had  occasion  to 
notice  in  several  cases  of  diabetes.  This  is  proba- 
bly to  be  regarded  as  a  reflex  manifestation  corre- 
sponding to  the  phenomena  occurring  with  gastric 
ulcer  and  gall-bladder  inflammations. 

Whenever  the  sensitiveness  is  in  the  epigastrium, 
it  is  necessary,  owing  to  the  close  relation  of  vascu- 
lar disease  to  disease  of  the  pancreas,  to  think  of 
the  possibility  of  purely  vascular  pain  (haemor- 
rhages or  atheroma  of  the  aorta).  When  sensitive- 
ness occurs  along  the  right  costal  border,  even  when 
sure  of  the  presence  of  pancreatic  disease,  we  must 
not  neglect  to  search  carefully  for  tumefaction  of 
the  gall-bladder.  This  may  easily  follow  constric- 
tion of  the  common  bile-duct  in  the  head  of  the 
pancreas. 

A  regular  relation  of  the  pains  in  diseases  of  the 
pancreas  to  the  taking  of  food  could  logically  be 


244  PAIN 

assumed  since  the  food,  passing  out  of  the  stomach 
two  or  three  hours  after  a  meal,  may  readily  cause 
pain  by  reflexly  inciting  pancreatic  secretion,  and 
therefore  producing  hyperaemia  of  the  organ ;  but,  of 
course,  whenever  such  a  direct  relation  between  the 
meal  and  the  attack  of  pain  occurs  it  would  be  more 
reasonable  to  think  of  secondary  pyloric  stenosis 
or  gastralgia. 

It  has  frequently  been  noticed  that  the  pain  in 
the  back  emanating  from  the  pancreas  occurs  with 
especial  frequency  at  night;  and  this  is  explained 
by  the  fact  that  the  dorsal  position  is  most  apt  to 
cause  discomfort. 

The  quality  of  the  pain  is  of  great  diagnostic 
importance,  in  that  it  frequently  occurs  with  great 
suddenness  and  severity  and  is  accompanied  by  signs 
of  collapse. 

The  factors  influencing  the  pain  are  naturally 
dependent  upon  the  mechanism  underlying  each  in- 
dividual attack.  In  cases  in  which  we  are  dealing 
with  true  neuralgia  without  the  presence  of  other 
factors,  it  is  quite  impossible  to  influence  the*  pains 
in  any  way  except  by  occasionally  effectual  narcotics. 

In  cases  where  the  pain  is  due  to  pressure  of 
tumors  (cyst  or  neoplasms),  or  is  caused  by  peri- 
toneal adhesions  to  the  surrounding  organs  (as  in 
pancreatic  abscesses),  the  conditions  are  quite  dif- 
ferent. In  such  cases  purely  mechanical  causes, 
jarring  and  tugging  upon  compressed  nerves  in 
rapid  change  of  position,  stooping,  coughing,  or  deep 
breathing,  may  exert  a  very  marked  influence  upon 


DIGESTIVE  SYSTEM  245 

the  pains.  Thus  in  the  case  of  cysts  and  neoplasms 
the  dorsal  position  is  very  painful,  and  turning 
upon  the  side  brings  almost  immediate  relief.  When- 
ever we  are  sure  of  the  presence  of  a  pancreatic 
lesion  and  we  can  obtain  immediate  relief  from  the 
pains  by  the  belching  following  the  administration 
of  alkaloids,  we  may  conclude  that  there  is  present 
a  secondary  stenosis  of  the  duodenum  with  conse- 
quent distention  of  the  stomach. 

"When  the  pains  have  a  purely  vascular  origin  we 
may  expect  them  occasionally  to  be  initiated  by 
the  hyperaemia  accompanying  digestion. 

Since,  in  a  general  way,  the  diagnostic  aid  given 
us  by  the  pain  in  these  cases  is  extremely  small,  it 
is  very  important  to  consider  closely  all  other  pos- 
sible clues.  We  must  remember  that  a  large  propor- 
tion of  the  cases  of  pancreatic  disease  occurs  in  very 
stout  alcoholic  individuals ;  and  that  these  are  espe- 
cially prone  to  arteriosclerosis  and  therefore  to 
hsemorrhage  and  necrosis. 

It  is  well  also  to  think  of  the  possibility  of  a 
pancreatic  lesion  in  all  cases  of  apparent  peritonitis, 
or  intestinal  obstruction.  The  same  holds  true  of 
all  cases  of  colicky  abdominal  pains  which  follow  a 
trauma,  blows  in  the  epigastrium,  etc.  If  in  these 
cases  no  indican  is  found  in  the  urine,  but  glycosuria 
appears  spasmodically  or  constantly  after  the  attack 
of  pain,  the  suspicion  of  a  pancreatic  lesion  becomes 
strong.  This  opinion  is  much  strengthened  if,  in 
addition  to  these  signs,  the  stools  show  an  insuf- 
ficient digestion  of  albumins  and  fats,  and  physical 


246  PAIN 

examination  justifies  the  consideration  of  pancreatic 
disease. 

In  spite  of  all  these  things  it  will  often  be  impos- 
sible to  distinguish  diseases  of  the  pancreas  from 
peritonitis,  acute  intestinal  stenosis,  cholelithiasis, 
gastralgia,  etc. 

Some  of  the  lesions  of  the  pancreas  are  accom- 
panied by  pains  of  definite  quality  which,  while  not 
entirely  characteristic,  may  still  give  much  diag- 
nostic aid. 

(a)  Carcinoma  of  the  Head  of  the  Pancreas. — 
Pain  in  the  back  with  occasionally  definite  relation 
to  the  position  of  the  body  may  occur.  This  is  by 
no  means  a  rule.  The  first  pains  seem  frequently 
to  occur  in  the  neighborhood  of  the  gall-bladder  be- 
cause of  the  overdistention  or  stenosis  of  the  com- 
mon bile-duct.  The  pains  seem  to  be  dependent 
chiefly  upon  mechanical  conditions,  such  as  the  posi- 
tion of  the  body,  and  are  similar  in  this  respect  to 
those  occurring  in  the  gall-bladder.  Again  the  first 
pains  may  be  dependent  entirely  upon  the  local 
perihepatitis  which  accompanies  the  subperitoneal 
metastases. 

In  this  way,  in  some  cases,  the  entire  attention 
of  the  physician  may  be  concentrated  upon  the  liver 
and  gall-passages,  and  the  pancreatic  lesion  may 
escape  detection.  In  the  same  way  the  attention 
may  be  directed  chiefly  toward  the  pylorus  or  duode- 
num when  subjective  or  objective  symptoms  of  ste- 
nosis occur  in  these  places.  When  this  occurs,  how- 
ever, the  pains  are  much  less  severe  than  in  the 


DIGESTIVE   SYSTEM  247 

primary  ulcerative  or  stenotic  processes  of  these 
organs. 

(b)  Pancreatic  Cyst. — In  this  condition  very  sud- 
den attacks  of  pain  occur,  sometimes  under  the  left, 
sometimes  under  the  right  costal  border,  accompa- 
nied by  syncope,  collapse,  vomiting  and  diarrhoea. 
These  attacks  may  in  part  be  due  to  sudden  increase 
of  tension  whenever  the  cyst  contents  rapidly  in- 
crease in  volume.    Again,  they  may  be  neuralgic 
in  their  nature,  or  may  consist  in  the  colic  following 
secondary  stenosis  of  the  gut. 

(c)  Suppurative  Pancreatitis. — Not  rarely  the 
acute  attack  of  pain  which  occurs  in  these-  cases  is 
followed  by  icterus.     This  would  naturally  lead  to 
the  danger  of  confusing  the  condition  with  choleli- 
thiasis.    The  error  can  be  guarded  against  only  by 
very  careful  palpation  and  localization  of  the  sensi- 
tive point. 

(d)  Hemorrhages. — When  we  are  dealing  with 
drunkards,   very   fat   people,    or   individuals   with 
marked  arterial  changes,  all  sudden  attacks  of  epi- 
gastric pain  accompanied  by  collapse  and  dangerous 
symptoms  must  be  considered  as  possibly  due  to  a 
haemorrhage  into  the  pancreas.    It  is  almost  never 
possible  to  make  this  diagnosis  with  certainty. 

(e)  Pancreatic  Calculi. — Attacks  of  pain  which 
are  due  to  stones  in  the  pancreatic  duct  usually  be- 
gin in  the  left  half  of  the  epigastrium  and  radiate 
over  the  left  shoulder.    This  left-sided  localization 
occasionally  permits  their  differentiation  from  the 
very  similar  attacks  of  gall-stone  colic,  a  differen- 


248  PAIN 

tiation  which  is  rendered  very  difficult  by  the  fact 
that  occasionally  pancreatic  concretions  are  accom- 
panied by  icterus.  The-  absence,  too,  of  sensitiveness 
to  pressure  over  the  gall-bladder  would  be  of  great 
aid.  Differentiation  from  ulcerations  similarly 
localized,  for  instance  those  occurring  in  the  py- 
lorus, can  be  made  by  considering  the  independence 
of  the  pancreatic  pains  from  the  quality  and  quan- 
tity of  the  food.  The  greatest  weight  in  making 
these  difficult  diagnoses  must,  of  course,  be  laid 
upon  the  secondary  symptoms. 

Diarrhoea  must  be  very  carefully  inquired  for, 
since  it  is  rather  a  rare  symptom  in  the  other 
varieties  of  colic.  In  addition  to  this  careful  exam- 
ination must  be  made  for  the  detection  of  glycosuria 
and  of  excess  of  fat  in  the  stools.  The  stools,  too, 
should  be  searched  for  bile-free  concretions  consist- 
ing of  carbonates  and  phosphates  of  calcium. 


CHAPTER  VIII. 

URINAKY  SYSTEM  AND  SPLEEN. 
KIDNEY. 

IN  discussing  the  factors  which  produce  pain  in 
the  urogenital  system,  we  may  avoid  much  repetition 
by  calling  attention  to  the  close  analogy  existing 
between  this  system  and  that  of  the  liver  and  gall- 
ducts.  The  pelvis  of  the  kidney,  the  ureter  and  the 
bladder  find  close  analogies  in  the  gall-bladder,  the 
gall-passages  and  the  duodenum,  and  in  a  general 
way  the  conditions  producing  colicky  pains  along 
these  hollow  muscular  organs  are  the  same.  It  may 
be  assumed  that  conditions  which  produce  an  in- 
crease of  pressure  upon  the  capsule  of  the  liver, 
such  as  congestion  of  blood  or  bile,  or  tumor  forma- 
tion, may  find  close  analogies  in  the  kidney  itself. 
The  same  holds  good  of  perihepatitis  and  peri- 
nephritis.  For  this  reason  we  can  follow  approxi- 
mately the  same  classification. 

I.    True  Kidney  Pains. 

Here  the  pain  is  caused  by  acute  or  chronic 
tension  upon  the  kidney  capsule  or  inflammatory 
changes  in  the  surrounding  tissue.  In  some  cases 
also  there  may  be  direct  injury  by  destructive  proc- 
esses of  the  renal  plexus.  At  any  rate  it  is  never 
correct  to  speak  of  renal  colic;  for  in  the  kidney 
itself  the  conditions  for  the  production  of  such 

249 


250  PAIN 

colicky  pains  are  absent,  such  pains  occurring  only 
in  hollow  organs. 

While  it  is  impossible  to  differentiate  by  their 
pains  alone  the  various  conditions  which  produce 
such  stretching  of  the  capsule  of  the  kidney,  it  is  for 
practical  reasons  better  to  consider  the  conditions 
separately. 

(a)  Embolism  of  the  Renal  Arteries. — It  is  ex- 
tremely rare  for  this  lesion  to  be  accompanied  by 
pain.  In  the  year  1901  I  was  able  to  find  in  the 
literature  only  seven  reported  cases,  and  therefore 
it  may  seem  wrong  to  begin  our  considerations  with 
this  condition.  But  in  kidney  infarcts  the  pain 
occurs  in  such  a  characteristically  sudden  way  that 
it  furnishes  a  most  clear-cut  subject  for  study. 

The  pain  in  this  condition  is  distinguished  from 
all  other  true  kidney  pains  only  by  the  great  sudden- 
ness of  its  onset  (apoplectiform).  In  other  respects 
every  one  of  the  details  which  are  observed  in  kidney 
pains  occurs,  and  for  this  very  reason  a  close  de- 
scription of  the  condition  will  serve  most  excellently 
to  illustrate  the  others. 

Subjective  pains,  as  well  as  the  objective  ones 
produced  by  pressure,  palpation  and  percussion,  cor- 
respond in  a  general  way  to  the  position  of  the 
organ  in  front  and  behind.  The  kidney  extends 
vertically  from  the  middle  of  the  eleventh  thoracic 
vertebra  to  the  lower  limit  of  the  body  of  the  second 
lumbar  vertebra.  In  an  upward  direction,  therefore, 
it  extends  to  above  the  twelfth  thoracic  vertebra. 
Its  posterior  surface  for  a  short  distance  is  apposed 


URINARY  SYSTEM  AND  SPLEEN         251 

to  that  part  of  the  diaphragm  at  which  the  lumbar 
and  costal  portions  of  this  organ  join.  The  greater 
part  of  it  lies  against  the  quadratus  lumborum. 
Since  the  kidney  varies  much  in  its  localization  we 
must  occasionally  be  prepared  to  find  abnormal  local- 
ization of  the  pain.  Thus  a  low  position  of  the  kid- 
ney may  give  rise  to  pains  in  the  ileocsecal  region. 
It  must  be  remembered  also  that  in  some  cases  the 
kidney  may  have  projections  towards  the  median 
line  (horse-shoe  kidney),  or  occasionally  in  the  pel- 
vis, or  the  sacrum,  along  the  position  of  the  sacro- 
iliac  junction.  These  abnormal  positions  would 
naturally  bring  with  them  abnormal  positions  of  the 
pain. 

The  kidney  pain  is  especially  easy  to  recognize 
when  we  are  dealing  with  the  right  kidney  and  the 
pains  are  projected  forwards.  This  occasionally 
happens  in-  renal  infarcts.  If  we  consider  the  sec- 
ondary symptoms,  such  as  vomiting,  pain  in  the  liver 
due  to  congestion,  tenderness  along  the  gall-bladder 
and  appendix,  and  fever,  the  danger  of  confusion 
with  gall-bladder  or  appendicular  pain  is  extremely 
probable. 

It  seems  to  the  author  especially  important  to 
note  that  the  pain  in  disease  of  the  kidney  is  located 
particularly  in  the  flank;  while  along  the  mammary 
line  in  front,  or  in  the  lumbar  region  behind,  the 
tenderness  to  pressure  or  percussion  is  much  less 
marked. 

Another  source  of  frequent  error  lies  in  the  fact 
that  pressure  of  the  abdomen  often  gives  rise  to  a 


252  PAIN 

very  diffuse  pain  (especially  when  the  infarction  is 
bilateral).  This  is  explained  by  the  fact  that  the 
pressure  reaches  the  diseased  organ  indirectly 
through  the  interposed  organs.  For  the  more  exact 
localization  of  the  pain  in  these  cases  percussion  is 
more  useful  than  palpation. 

The  patient  in  cases  of  true  kidney  pain  almost 
always  localizes  the  pain  deeply,  away  from  the 
abdominal  wall,  a  fact  which  often  helps  greatly  in 
differentiating  it  from  neuralgia  or  myalgia. 

Very  occasionally  there  is  sensitiveness  in  the 
lower  intercostal  spaces  as  far  up  as  the  scapular 
angle  posteriorly,  and  about  four  centimeters  above 
the  costal  border  anteriorly.  This  must  be  regarded 
as  merely  a  reflex  pain,  since  it  occasionally  occurs 
in  pyelonephritis  without  the  existence  of  a  second- 
ary pleural  inflammation. 

Sensitiveness  to  pressure  is  found  chiefly  in: 
(1)  the  flank,  in  the  axillary  line;  (2)  the  angle 
between  the  lateral  border  of  the  erector  spina*  and 
the  twelfth  rib;  (3)  anteriorly  in  the  region  below 
the  gall-bladder  corresponding  to  the  position  of  the 
kidney. 

A  characteristic  radiation  does  not  accompany 
these  true  kidney  pains  and  therefore  is  not  present 
with  renal  infarcts.  This  is  due  to  the  absence  of  a 
path  of  transmission  (ureter) ;  yet  in  rare  cases 
there  may  be  sensations  in  the  thigh.  When  these 
do  occur,  they  can  be  regarded  as  due  to  pressure 
upon  the  twelfth  dorsal  nerve  and  branches  of  the 
lumbar  plexus,  by  thickening  of  the  capsule. 


URINARY  SYSTEM  AND   SPLEEN         253 

The  factors  influencing  the  pains  of  renal  inf arct 
are  chiefly  mechanical.  Normally  the  kidney  is  sup- 
posed to  be  entirely  immovable.  This  is  quite  theo- 
retical, however,  and  practically  we  may  find  all 
degrees  of  mobility.  It  is  not  surprising,  therefore, 
that  in  cases  of  inflammatory  changes  within  the 
kidney  or  about  the  capsule  (partial  necrosis  of  the 
renal  tissue,  tuberculosis,  etc.),  forcible  manipula- 
tion of  the  organ  is  accompanied  by  more  or  less 
pain;  thus,  too,  a  definite  position  of  greatest  pain 
is  developed  quite  acutely  in  cases  where  enterop- 
tosis  and  weakness  of  the  abdominal  walls  are  pres- 
ent. The  patients  are  unable  to  lie  on  either  side 
without  suffering,  and  it  is  peculiar  that  pain  is 
most  severe  when  lying  upon  the  healthy  side.  In 
this  position  they  have  the  sensation  of  a  painful 
tugging  extending  from  the  diseased  side  towards 
the  healthy.  The  actual  descent  of  the  kidney 
downwards  toward  the  side  upon  which  he  lies  is 
felt  acutely  and  distinctly  by  the  patient. 

In  the  same  way  definite  painful  positions  are 
present  in  tuberculosis,  in  renal  tumors  and  in  pyelo- 
nephrosis;  only  occasionally  does  the  position  of 
greatest  pain  correspond  with  the  diseased  side.  If 
change  of  position  and  slight  tugging  by  reason  of 
the  weight  of  the  organ  itself  are  able  to  cause  pain, 
it  is  all  the  more  reasonable  to  believe  that  forcible 
jarring  would  cause  localized  pain  in  the  neighbor- 
hood of  the  kidney;  and  this  actually  occurs  with 
coughing,  vomiting,  riding  in  a  carriage,  jumping, 
or  making  a  false  step.  All  motions  which  call  for 


254  PAIN 

contraction  of  the  ileopsoas  muscle,  such  as  rising, 
and  stretching  of  the  flexed  thigh,  will  of  course 
give  pain  because  of  the  close  apposition  of  the 
kidney  to  the  muscle. 

It  is  hardly  necessary  to  mention  that  pressure 
in  the  kidney  region,  or  percussion  with  the  clenched 
fist  would  cause  pain.  Strong  percussion  is  espe- 
cially helpful  in  localizing  the  exact  extent  of  the 
pain  and  in  demonstrating  its  diminution  during  con- 
valescence. It  is  worth  mentioning,  too,  that  in 
cases  of  renal  infarct  the  objective  pain  is  present 
for  some  time  after  the  subjective  has  disappeared. 

The  pain  accompanying  renal  infarct  resembles, 
in  the  suddenness  of  its  onset,  colic  of  the  ureter, 
but  is  sharply  differentiated  from  the  latter  condi- 
tion by  the  fact  that  the  pain  itself,  after  the  onset, 
is  not  colicky  but  stabbing,  aching  and  constant. 

In  attributing  any  pain  to  renal  infarction,  we 
must  consider  the  condition  of  the  heart  (existence 
of  a  mitral  stenosis).  "We  must  note  particularly 
the  sudden  onset  of  the  pain  and  the  subsequent 
absence  of  any  paroxysmal  quality.  Most  abdom- 
inal pains  are  of  a  colicky  nature,  and  the  absence 
of  the  paroxysmal  element  is  of  great  differential 
importance. 

It  is,  furthermore,  very  important  to  determine 
whether  or  not  there  is  difficulty  of  micturition. 
Urination  becomes  difficult  (renal  dysuria)  and  can 
be  accomplished  only  in  the  standing  position  and 
with  great  exertion;  occasionally  there  are  symp- 
toms of  moderate  incontinence.  The  quantity  may 


URINARY  SYSTEM  AND  SPLEEN         255 

be  at  first  diminished  or  there  may  even  be  complete 
anuria.  The  frequent  desire  to  urinate  seems  to 
be  absent  in  these  cases,  a  feature  which  is  of  great 
differential  value  since  pains  arising  in  the  excretory 
passages  are  usually  accompanied  by  this  symptom. 

The  characteristic  features  of  the  urine  analysis, 
I  have  found  to  be  the  following : 

There  is  often  a  sudden  and  copious  albuminuria, 
as  high  as  2  per  cent.,  which  very  rapidly  diminishes. 
There  is  occasionally  a  very  slight  hsematuria,  often 
discovered  only  by  microscopical  examination.  Oc- 
casionally, also,  epithelial  casts  may  be  found  in  the 
sediment. 

The  consideration  of  these  secondary  symptoms 
which  point  to  the  urogenital  system  will  guard  us 
against  confusion  with  the  colics  of  the  gall-bladder 
and  appendix,  an  error  which  is  the  more  easily 
made  when  the  embolus  is  situated  on  the  right  side. 

The  vomiting  and  hiccoughing  which  occur  with 
the  onset,  can  lead  easily  to  the  false  diagnosis  of 
acute  peritonitis.  This  is  especially  so  when  the 
infarct  is  bilateral  and  in  consequence  the  abdom- 
inal tenderness  is  very  diffuse. 

The  pain  accompanying  renal  infarct  is  sharply 
differentiated  from  the  pains  which  occur  along  the 
ureter  (nephrolithiasis)  by  the  complete  absence 
of  paroxysms,,  the  continuous  character  of  the  pains, 
and  the  slight  tendency  to  radiation.  In  ureteral 
colic  the  pain  is  of  a  remarkably  intermittent  type 
and  radiations  are  very  frequent.  In  renal  infarc- 
tion the  kidney  is  especially  sensitive  to  pressure, 


256  PAIN 

whereas  in  the  other  condition  tenderness  may  occur 
only  along  the  course  of  the  ureter. 

It  is  quite  impossible  to  differentiate  the  pain  of 
renal  infarct  from  that  accompanying  other  intra- 
renal  conditions.  All  other  diseases  which  occur 
in  this  location  may  give  rise  to  similar  pains,  and 
for  that  reason  the  description  just  given  may  serve 
as  a  type  for  all  true  "nephralgia."  I  will  there- 
fore spend  little  time  in  discussing  the  other  patho- 
logical conditions  which  occur  in  the  kidney  and  are 
accompanied  by  pain. 

(b)  Acute  and  Chronic  Nephritis,  Pyelitis,  and 
Paranephritis. — Acute  paroxysmal  pains  may  occa- 
sionally, though  rarely,  accompany  the  non-suppura- 
tive  inflammations  of  the  kidney.  These  are  then 
due  to  pericapsular  inflammation,  and  damming  back 
of  the  urine,  with  acute  congestion  and  increase  in 
the  capsular  tension.  Thus  acute  hyperaemia,  as  it 
occurs  in  cases  of  nephritis,  may  give  rise  to  intense 
pains  which  are  similar  to  those  just  described  in 
renal  infarct,  and  these  pains  may  be  one-sided  in 
spite  of  symmetry  in  the  pathological  process.  It 
is  therefore  advisable  to  be  very  cautious  in  the 
diagnosis  of  calculus  when  sudden-  colicky  pain 
occurs  in  the  neighborhood  of  the  kidney  in  acute 
nephritis,  even  when,  as  in  one  of  my  own  cases, 
radiation  occurs  into  the  thigh.  Such  an  occurrence, 
while  it  must  be  thought  of,  is  nevertheless  extremely 
rare  in  all  cases  of  non-suppurative  nephritis.  I 
have  seen  onlv  one  such  case. 


URINARY  SYSTEM  AND  SPLEEN         257 

Of  much  greater  frequency  are  those  uncertain 
dull  back-aches,  the  relation  of  which  to  the  kidney 
is  subject  to  great  doubt  and  must  be  judged  individ- 
ually in  each  case.  It  is  very  rare  that  we  have  any 
definite  factor  which  points  to  the  kidney  as  the 
source  of  the  pain.  I  have  seen  cases,  however,  in 
which  the  patient  has  stated  that  excessive  drinking 
has  increased  the  pain,  while,  on  the  other  .hand, 
discharge  of  the  urine  has  decreased  it  considerably. 

In  contrast  to  lumbago,  the  pain  in  nephritis  and 
pyelonephritis  is  not  at  all  influenced  by  stooping; 
while,  on  the  other  hand,  walking  about,  severe  exer- 
tion, and  pressure  increase  the  pains,  just  as  in  the 
case  of  lumbago.  In  these  conditions,  too,  the  pain 
is  occasionally  one-sided.  As  a  matter  of  practical 
importance  it  is  well  to  examine  the  urine  for  al- 
bumin in  all  cases  where  a  pain  suggestive  of  lum- 
bago exists,  and  this,  especially,  when  no  other 
clearly  rheumatic  pains  are  present. 

It  is  also  important,  whenever  albuminuria  has 
been  discovered,  to  examine  the  kidney  for  tender- 
ness. Occasionally,  hypersemia  of  the  kidney  and 
consequently  increased  intracapsular  pressure  will 
give  rise  to  sensitiveness  on  palpation.  Percussion 
in  the  loin  is  best  made  with  the  clenched  fist.  By 
palpation  in  front  it  is  often  possible  to  press 
directly  upon  the  lower  pole  of  the  kidney.  When- 
ever slight  pressure  in  the  loin  or  slight  jarring  in 
this  neighborhood  causes  pain  and  we  can  determine 
the  presence  of  hyperaesthesia  along  the  ileohypo- 
gastric  and  genitocrural  nerves,  we  must  think  of 

17 


258  PAIN 

the  possibility  of  paranephritic  suppuration.  In 
such  cases  the  patient  often  lies  with  the  thigh  flexed 
and  adducted,  has  chills,  and  suffers  great  pain  upon 
change  of  position. 

(c)  Renal  Congestion. — Just  as  the  liver  is  the 
seat  of  pain  when  it  is  congested  in  consequence  of 
cardiac  insufficiency,  so  the  kidney  may  be  the  seat 
of  pain  under  similar  conditions.     This,  however, 
occurs  much  more  rarely.     The  pains  in  the  back 
are  then  very  promptly  relieved  by  digitalis. 

(d)  New  Growths  of  the  Kidney. — Pain  in  the 
lumbar  region  and  the  flank,  when  unilateral,  must 
occasionally  arouse  suspicion  of  an  early  neoplasm 
of  the  kidney  and  should  lead  to  a  careful  palpation 
of  the  organ. 

Increase  in  the  intracapsular  tension  in  conse- 
quence of  the  enlargement  of  the  new  growth,  con- 
gestion or  haemorrhage  into  the  tumor,  may  give  rise 
to  pain,  even  in  the  early  stages.  In  these  cases,  too, 
the  pains  havethe  characteristics  of  true  kidney  pains 
in  the  special  sense  of  the  word,  and  correspond  to 
the  pains  described  for  renal  infarct.  In  conse- 
quence of  the  increased  weight  of  the  organ  the  tug- 
ging pains  accompanying  change  of  position  will  be 
more  noticeable  than  in  infarction,  so  that  the  patient 
cannot  bear  to  lie  on  the  side  opposite  to  that  of  the 
diseased  kidney.  The  pain  is  often  provoked  by 
bending,  lifting,  or  the  carrying  of  a  heavy  weight. 
This  may  be  due  either  to  temporary  passive  hyper- 
semia  or  to  direct  pressure  by  the  contracting  abdom- 
inal muscles.  In  these  cases,  too,  there  may  occa- 


URINARY   SYSTEM   AND   SPLEEN          259 

sionally  be  sensitiveness  to  pressure  in  the  corre- 
sponding thigh. 

When  the  new  growth  penetrates  into  the  pelvis 
of  the  kidney  and  secondary  haemorrhage  occurs,  a 
new  source  of  pain  arises ;  but  then  we  are  dealing 
with  the  colicky  pain  belonging  to  the  urinary  pas- 
sages which  will  be  spoken  of  in  a  later  section. 

(e)  Tuberculosis  of  the  Kidney. — In  many  cases 
tuberculosis  of  the  kidney  occurs  without  local  pain. 
Nevertheless  cases  occur  in  which  pain  is  one  of  the 
earliest  symptoms.  Whenever  considerable  capsu- 
lar  or  pericapsular  inflammation  occurs,  nephralgia 
will  be  present,  and  such  pains,  in  the  presence  of  a 
tuberculous  tendency  or  of  tuberculosis  in  other 
parts  of  the  body,  must  always  arouse  suspicion. 
The  pain  seems  to  be  in  many  cases  extremely 
acute,  and  is  described  as  boring  like  that  of  a  boil. 

Just  as  in  new  growth,  so  in  tuberculosis  of 
the  kidney  sudden  paroxysmal  attacks  may  occur. 
These  occur  whenever  by  ulceration  and  erosion  of 
a  blood  vessel  a  haemorrhage  takes  place  into  the 
pelvis  from  one  of  the  papillae. 

The  localization  of  the  subjective  and  objective 
pains  in  this  condition  corresponds  more  or  less 
closely  to  that  described  for  renal  infarct.  The 
painful  sensations  which  occasionally  occur  in  the 
bladder  and  urethra,  without  any  disease  in  these 
organs,  must  be  explained  by  radiation,  and  consist 
chiefly  in  a  painful  desire  to  urinate,  and  burning 
pain  before  and  after  micturition;  so  that  these 
pains  may  simulate  a  cystitis. 


260  PAIN 

(f)  Paroxysmal  Hcemoglobinuria. — In  this  con- 
dition there  is  occasionally  an  acute  hyperjemia  of 
the  kidney  with  consequent  intracapsular  pressure; 
the  pain  in  the  back  which  occurs  is  probably  to  be 
interpreted  upon  this  basis. 

The  subjective  pain  which  occurs  in  one  or  both 
kidneys  is  often  accompanied  by  sensitiveness. 
The  pain  is  then  dependent  upon  motion,  such  as  ris- 
ing from  a  stooping  position,  bending  forward  and 
turning  towards  the  painful  side. 

(g)  Movable  Kidney. — It  must  be  remembered, 
in  considering  movable  kidney,  that  many  patients 
in  whom  an  enormous  amount  of  freedom  of  motion 
of  the  kidney  exists  are  almost  entirely  free  from 
pain.     This  fact  ought  to  be  considered  very  seri- 
ously, because  it  is  a  quite  common  error  that  when 
a  movable  kidney  is  present  in  a  patient,  this  is  taken 
as  the  cause  for  any  existing  pain.    In  most  cases 
it  is  not  the  wandering  kidney  which  causes  the 
pains.     The  individuals  in  whom  they  are  present 
are  usually  of  an  extremely  neurasthenic  type,  and 
suffer  from  a  general  enteroptosis.     These  are  the 
conditions  which  should  be  treated  rather  than  that 
of  the  movable  organ  itself.    It  stands  to  reason  that 
in  this  condition  there  is  a  constant  tugging  on  the 
renal  plexus  and  indirectly  therefore  upon  the  solar 
plexus.    This  leads  naturally  to  hyperasthesia  in 
the  abdominal  sympathetic  system  and  consequent 
irritability  of  the  stomach,  gall-bladder  and  genitals. 
In  this  sense,  a  movable  kidney  and  enteroptosis 
may  be  very  disagreeable  complications  of  gastric 


URINARY  SYSTEM  AND  SPLEEN         261 

ulcer  or  cholelithiasis.  Whenever  an  abnormally 
movable  kidney  is  also  tender  and  sensitive  to  pres- 
sure, it  is  well  to  think  of  diseases  of  this  kidney, 
such  as  calculi,  pyelitis,  or  tuberculosis. 

In  referring  any  existing  pain  to  the  mobility  of 
the  kidney,  it  is  important  to  determine  whether 
motions  which  directly  result  in  tugging  or  jarring 
of  the  organ,  such  as  walking  downstairs,  rapid 
change  of  position,  etc.,  are  the  ones  which  cause  the 
pain;  and  it  is  never  just  to  attribute  pains  which 
are  present  during  absolute  quiet  to  this  cause.  It 
must  be  remembered,  however,  that  other  diseases 
which  are  often  accompanied  by  enteroptosis,  such 
as  ulcer,  chronic  appendicitis,  and  gall-bladder  dis- 
ease, may  also  be  dependent  upon  such  jarring 
movements. 

The  exact  diagnosis  in  these  cases  is  often  ex- 
tremely difficult,  and  it  is  better,  therefore,  to  let 
the  therapeutic  interference  precede  the  diagnosis 
rather  than  vice  versa.  Whenever  the  pain  is  re- 
lieved when  the  kidney  is  immobilized  by  bandages, 
the  diagnosis,  of  course,  is  cleared  up. 

It  is  surely  very  rare  that  torsion  of  the  pedicle 
of  a  movable  kidney  occurs;  and  it  is  well  to  think 
of  this  only  after  the  exclusion  of  other  causes  for 
the  attack.  Whenever  this  does  occur  the  pain  that 
accompanies  it  can  be  explained  in  two  ways: 
1.  Acute  venous  stasis.  2.  Acute  development  of 
ureteral  obstruction  with  secondary  hydronephrosis. 
In  both  cases  local  sensitiveness  would  be  easily  ex- 
plained. In  the  second  case,  however,  an  attack  of 


262  PAIN 

polyuria  would  theoretically  be  expected  towards 
the  end  of  the  attack.  On  the  other  hand,  it  is  well 
to  remember  that  in  neurasthenic  individuals,  among 
whom  the  large  majority  of  movable  kidneys  occur, 
polyuria  is  not  a  rare  symptom. 

II.  Pains  Caused  by  Distention  and  Muscular  Spasm 
along  the  Urogenital  Tract   (Renal 
Pelvis  and  Ureter). 

The  pains  which  are  considered  in  this  connec- 
tion are  in  their  genesis  closely  related  to  those 
occurring  in  the  gall-bladder  system,  and  may  easily 
be  classified  in  the  same  way.  The  pelvis  of  the  kid- 
ney may  be  regarded  as  analogous  to  the  gall- 
bladder and  the  urinary  bladder  to  the  duodenum. 

The  characteristics  which  distinguish  the  pains 
in  these  passages  from  the  true  kidney  pain  (ne- 
phralgia)  are  the  marked  tendency  to  colicky  attacks 
and  the  tendency  to  radiation ;  for  we  have  here  in 
contradistinction  to  the  kidney  itself  a  channel  for 
radiation  along  the  ureter  and  bladder.  The  chief 
causes  which  may  give  rise  to  colicky  attacks  in  the 
genito-urinary  ducts  are  analogous  to  those  which 
give  rise  to  similar  pains  in  the  gall-duct  system. 

1.  Stenotic  Processes. — The  most  important 
causes  for  stenosis  are :  (a)  Calculi,  blood  clots,  par- 
ticles of  new  growth,  and  aortic  aneurysm  (on  the 
left  side),  (b)  Kinking  and  torsion,  (c)  Carci- 
noma of  the  bladder  at  the  points  of  entrance  of  the 
ureters.  (This  would  be  analogous  in  the  bile  pas- 
sages to  a  carcinoma  at  the  papilla  of  Vater  or  in 
the  head  of  the  pancreas.) 


URINARY  SYSTEM  AND   SPLEEN         263 

2.  Inflammatory  Processes,  Ascending  and  De- 
scending.— Pyelitis  with  or  without  the  formation 
of  calculi ;  this  may  or  may  not  extend  into  the  small 
tubules  of  the  kidney  (pyelonephritis).  Ureteritis 
is  entirely  analogous  to  cholecystitis  and  cholan- 
geitis,  while  the  pyelonephritis  can  be  compared  with 
Hanot's  biliary  cirrhosis. 

All  these  conditions,  and  especially  the  formation 
of  calculi  in  the  kidney  pelvis,  give  rise  to  colicky, 
paroxysmal  pains.  On  the  other  hand,  they  may 
also  give  rise  to  more  constant  pains,  not  colicky  in 
their  nature,  the  understanding  of  which  is  of  ex- 
treme importance.  These  more  constant  pains  are 
probably  due  to  a  moderate  degree  of  distention 
along  the  ureters  or  pelvis.  It  must  be  remembered, 
too,  that  any  pathological  process  in  the  renal  pelvis 
easily  involves  the  kidney  itself,  even  when  it  is  only 
a  temporary  damming  back  of  urine  or  an  active 
hypersemia;  and  this,  in  its  turn,  can  give  rise  to 
the  true  kidney  pain  which  we  have  spoken  of  before. 

As  a  practical  matter  it  is  almost  impossible  to 
separate  the  purely  stenotic  and  the  inflammatory 
processes  which  occur  along  the  renal  pelves  and  the 
ureters.  They  often  occur  at  the  same  time,  for 
stagnation,  as  is  well  known,  carries  with  it  the 
predisposition  to  infection.  For  this  reason  we 
may  disregard  this  purely  artificial  distinction  in 
the  consideration  of  the  pain. 

(a)  THE  FORMATION  OF  CALCULI  IN  THE  PELVIS  OF 
THE  KIDNEY. — Just  as  in  describing  the  true  kidney 
pain,  the  pain  caused  by  infarct  of  the  kidney  was 


264  PAIN 

used  as  a  type,  so  the  pains  occurring  in  the  pelves 
and  ureters  are  well  typified  in  a  general  way  by  the 
pains  caused  by  a  calculus  in  the  renal  pelvis. 

For  practical  reasons  it  is  well  to  divide  such 
pains  into  (1)  spontaneous  attacks  of  paroxysmal 
pain  or  colic,  (2)  more  constant  pains  not  colicky 
in  their  character  and  often  elicited  by  physical 
examination. 

(1)  The  localization  of  the  colicky  pains  is  rather 
apt  to  be  confusing  to  the  diagnostician.  Sometimes 
these  pains  occur  first  in  the  region  of  the  gall- 
bladder along  the  right  costal  border.  Occasionally 
they  have  their  seat  more  deeply  in  the  ileocascal 
region  or,  if  left-sided,  just  above  the  left  Poupart's 
ligament.  In  comparatively  rare  cases  the  lumbar 
region  may  be  the  starting  point  of  the  pains.  This 
is  not  at  all  surprising  when  we  consider  that  the 
lesion  upon  which  the  pain  is  based  has  its  seat,  not 
in  the  kidney  itself,  but  in  the  ureter. 

More  important  than  the  actual  location  of  the 
pain  is  the  radiation,  which  unfortunately  is  not 
always  present.  This  occurs  into  the  thigh  of  the 
same  side,  chiefly  radiating  down  the  anterior  or 
external  surface,  and  rarely  extending  further  down 
than  the  knee. 

We  must  be  on  the  watch,  too,  for  radiations  into 
the  bladder  and  the  genitals,  with  occasional  cramp- 
like  sensations  in  these  organs.  It  is  very  important 
to  remember  that  painful  sensations  in  the  testicles, 
ovaries  and  thighs  may  for  a  long  time  precede  the 
first  attack.  These  pains  occur  especially  at  night 


URINARY  SYSTEM  AND   SPLEEN         265 

and  their  diagnostic  importance  must  not  be  under- 
estimated. 

The  pain  not  infrequently  radiates  into  the  lum- 
bar regions;  upward  it  rarely  reaches  higher  than 
the  angle  of  the  scapula.  Whenever  the  attacks 
occur  spontaneously  they  seem  to  be  dependent  upon 
mechanical  agencies  rather  than  upon  digestive 
causes. 

Motions  which  give  rise  to  a  sudden  stiffening 
of  the  abdominal  walls,  lifting,  or  throwing,  seem 
frequently  to  have  a  causal  relation  to  the  begin- 
ning of  an  attack.  On  the  other  hand,  I  have  seen 
cases  in  which  attacks  have  been  initiated  by  the 
drinking  of  sour  wine,  the  taking  of  sour  food,  such 
as  vinegar,  and  occasionally  the  drinking  of  beer. 
Such  digestive  influences  upon  the  attacks  occur  nat- 
urally in  cases  in  which,  in  addition  to  calculus  for- 
mation, there  is  an  inflammatory  change  of  the 
mucous  membrane  of  the  pelvis  and  ureter  which 
is  irritated  by  the  reaction  of  the  urine  passing 
through  it. 

Whenever  a  paroxysm  ceases  with  great  sudden- 
ness we  are  led  to  believe  that  a  calculus  has  been 
discharged  into  the  bladder. 

The  secondary  symptoms  chiefly  to  be  consid- 
ered are  those  which  arise  from  the  urogenital  sys- 
tem and  therefore  point  directly  to  the  origin  of  the 
colicky  attack.  Chief  among  these  are  the  desire  for 
frequent  micturition  and  retention  of  urine.  In 
tuberculosis  of  the  kidney,  kidney  infarct,  and  other 
conditions  of  nephralgia  or  true  kidney  pain,  the 


266  PAIN 

desire  to  urinate  may  occasionally  entirely  disap- 
pear. 

Sometimes  there  is  definite  sensitiveness  of  the 
testicle  on  the  affected  side  with  occasional  swelling. 
Swelling  and  sensitiveness  in  the  urethra  may  be 
the  premonition  of  an  attack.  Very  definite  clews, 
of  course,  are  given  by  haematuria,  albuminuria,  ura- 
turia,  phosphoturia,  oxaluria,  and  cystinuria. 

Eeflex  symptoms,  aroused  in  other  organs  by 
the  renal  condition,  may  considerably  cloud  the  diag- 
nostic picture.  Meteorism  with  constipation,  diffuse 
distribution  of  the  pains,  with  collapse,  may  simu- 
late acute  intestinal  obstruction  and,  in  just  such 
cases,  the  extreme  sensitiveness  of  the  testicles  is  of 
distinct  diagnostic  importance.  The  distended  ab- 
domen itself  is  often  sensitive  to  pressure,  and  in 
such  cases  distention  and  sensitiveness  are  usually 
localized  more  on  one  side  than  on  the  other.  Occa- 
sionally there  may  be  no  pain  in  the  kidney  region 
itself.  Gastric  symptoms,  such  as  nausea  and  vomit- 
ing, occasionally  occur,  but  are  much  less  frequent 
than  in  connection  with  the  colics  of  the  biliary  sys- 
tem, and,  during  the  attacks  of  renal  pain,  the  diges- 
tive system  is  often  entirely  normal,  not  even  the 
appetite  being  changed.  In  many  cases  there  are 
subjective  sensations,  such  as  a  sensation  of  cold, 
etc.,  in  the  thigh  of  the  same  side.  There  may  also  be 
motor  symptoms,  such  as  spasm  in  the  muscles  of  the 
calf  or  the  thigh  of  the  same  side. 

Sensitiveness  to  pressure  along  the  ureter  on 
external  examination  per  rectum  or  pervaginam  is  of 


URINARY  SYSTEM  AND   SPLEEN         267 

the  greatest  importance,  and  from  this  examination 
alone  the  diagnosis  of  an  obstructing  calculus  can 
often  be  made. 

(2)  More  constant  pains  (without  paroxysmal 
quality).  Under  this  heading  we  include  chiefly 
pain  which  is  not  subjectively  present  but  is  discov- 
ered on  palpation.  We  have  already  called  atten- 
tion to  the  sensitiveness  of  the  testicle.  In  addition 
to  this  there  is  usually  sensitiveness  of  the  ureter, 
leading  on  the  right  side  to  pain  in  the  neighborhood 
of  the  appendix;  on  the  left  side  in  the  neighbor- 
hood of  the  sigmoid  flexure. 

The  sensitiveness  to  pressure  in  the  flank  and  to 
percussion  in  the  lumbar  region  is  of  great  impor- 
tance. The  maximum  point  of  sensitiveness  is  often 
located  just  above  Poupart's  ligament.  Occasion- 
ally when  the  condition  exists  on  the  right  side  the 
gall-bladder  is  very  sensitive  and  errors  may  arise 
from  this  fact.  When  this  is  the  case,  however,  very 
often  sensitiveness  in  the  gall-bladder  radiates 
towards  the  urinary  bladder  and  this,  of  course,  is 
of  great  importance. 

These  more  constant  pains  may  often  be  started 
by  the  patient's  lying  on  one  side.  When  the 
process  is  bilateral  lying  on  either  side  is  painful. 
In  some  cases  no  fixed  position  can  be  held  for  any 
length  of  time  without  great  pain.  We  spoke  of 
such  positions  of  greatest  pain  when  dealing  with 
cholecystitis,  and  here  again  symptoms  of  this  kind 
are  due  probably  to  changes  in  the  pelvis  of  the 
kidney;  they  may  also  be  caused  by  secondary  in- 


268  PAIN 

volvement  of  the  kidney  in  the  form  either  of  an 
acute  damming  back  of  the  urine,  or  an  acute  conges- 
tion of  the  kidney  itself.  Coughing,  deep  breathing, 
and  jarring  of  any  kind  may  give  pain  in  nephro- 
lithiasis. 

The  unilateral  neuralgia  of  the  testicle  which 
occurs  chiefly  at  night,  and  the  so-called  rheumatic 
pains  in  the  thigh,  may  often  precede  the  true  colicky 
attacks  by  many  years.  The  sensations  of  weakness, 
nausea,  etc.,  which  usually  accompany  the  colicky 
attacks  may  be  present  by  themselves  frequently, 
and  are  then,  almost  invariably,  wrongly  interpreted. 

Under  this  heading,  too,  we  must  consider  that 
pain  in  the  lumbar  region  which  frequently  accom- 
panies the  condition.  This  is  present  especially  in 
the  lying  and  sitting  postures,  and  is  less  marked 
when  walking.  Alone,  of  course,  the  recurrence 
of  such  a  pain  can  give  us  no  diagnostic  clue ;  but,  in 
connection  with  other  symptoms,  such  as  testicular 
pain  and  parsesthesia  of  the  thigh,  it  may  give  much 
additional  support  to  our  diagnosis. 

(b)  PYELITIS. — Of  chief  importance  are  the 
ascending  catarrhs  of  the  urinary  passages,  usually 
preceded  by  a  history  of  an  old  gonorrhoea,  so  that 
in  many  cases  the  ureter  and  the  bladder  itself  may 
be  regarded  as  diseased  together.  This  variety  of 
pyelitis  is  the  most  frequent.  The  pain  occurring 
in  this  condition  is  almost  identical  with  that  occur- 
ring in  cases  of  calculi.  This  fact  is  of  particular 
pathological  interest,  since  it  lends  support  to  the 
opinion  that  pains  of  this  description  are,  in  these 


URINARY  SYSTEM  AND   SPLEEN         269 

cases  as  well  as  in  gall-bladder  condition,  caused  by 
the  inflammatory  lesions  rather  than  by  the  mere 
mechanical  presence  of  calculi. 

Changes  of  the  kidney  in  all  their  transitions 
from  a  simple  inflammatory  hypersemia  to  a  fully 
developed  pyelonephritis  may  accompany  this  con- 
dition. A  part,  therefore,  of  the  clinical  picture  is 
made  up  of  the  true  kidney  pain  itself.  The  local- 
ization of  the  pain  is  much  the  same  as  that  men- 
tioned above.  Occasionally,  however,  cases  occur 
in  which  the  pain  and  sensitiveness  take  place  in  the 
region  of  the  gall-bladder  and  appendix  and  thus 
lead  to  error  in  diagnosis. 

The  radiation  is  identical  with  that  which  occurs 
in  calculi  of  the  renal  pelvis.  Radiation  may  occur 
at  the  same  time  as  the  colicky  attacks  or  may  be 
entirely  independent  of  them.  It  may  be  localized 
chiefly  on  the  outer  side  or  occasionally  on  the  inner 
side  of  the  thigh  of  the  same  side.  Prolonged  sit- 
ting occasionally  initiates  these  radiating  pains. 

In  isolated  cases  it  is  not  so  much  the  sensation 
of  pain  as  the  sensation  of  weakness  and  fatigue  in 
the  lower  extremity  of  the  same  side  as  the  disease 
which  gives  rise  to  a  suspicion  of  a  lesion  in  the 
renal  pelvis. 

Sometimes  sensitiveness  occurs  along  the  dorso- 
lumbar  portion  of  the  spinal  column.  Pain  occur- 
ring while  the  patient  is  lying  on  his  side  is  located 
usually  in  the  side  opposite  to  that  of  the  lesion. 
Frequently  the  pain  which  occurs  in  this  posture  is 
present  only  during  the  acute  attack  and  disappears 
when  the  attack  is  over. 


270  PAIN 

There  is  often  a  tendency  towards  relaxation  of 
the  abdominal  muscles  on  the  diseased  side.  The 
patients  lean  toward  that  side  while  walking  or  sit 
in  a  cramped  position.  Sudden  stretching  of  the 
abdominal  muscles  often  brings  about  an  attack  of 
intense  pain  and  syncope,  in  cases  which  have  been 
before  that  almost  free  from  pain.  In  doubtful 
cases  it  is  often  advisable  to  test  cautiously  the 
influence  of  lifting  or  carrying  weights  on  the  back. 
Violent  jarring,  such  as  is  produced  by  stamping 
the  foot,  jumping,  etc.,  will  frequently  give  rise  to 
pain.  In  contradistinction  to  lumbago,  the  pain  is 
not  increased  by  stooping,  even  when  there  has  pre- 
viously been  severe  pain  in  the  lumbar  region. 

Catching  cold  and  exposure  to  wet  often  give  rise 
to  attacks  of  pain.  This  is  probably  due  to  the  fact 
that  these  conditions  may  provoke  an  acute  exacer- 
bation of  a  chronically  inflamed  condition  of  the 
mucous  membrane. 

It  need  hardly  be  emphasized  that  careful  micro- 
scopical examination  of  the  urine  and  careful  atten- 
tion to  the  temperature  are  desirable.  Pyemic  tem- 
perature frequently  occurs  and  the  individual  par- 
oxysmal attacks  may  be  accompanied  by  a  chill  and 
subsequent  sweating.  Fever  may  precede  the  at- 
tacks for  some  time,  for  the  infectious  agent,  which 
not  infrequently  is  B.  coli  or  staphylococcus,  plays 
an  important  role  in  these  cases. 

The  most  important  secondary  symptoms  are  fre- 
quent desire  to  micturate  and  ardor  urinae. 


URINARY  SYSTEM  AND   SPLEEN          271 

(c)    HEMORRHAGE  FROM   THE  KlDNEYS. — Bleeding 

from  the  kidney  can  unquestionably  give  rise  to 
paroxysmal  attacks  of  pain,  so  that  the  expression 
Nephralgie  hcematurique  is  fully  justified. 

It  is  very  important  to  remember  that  cases  of 
prolonged  and  constant  haematuria  exist,  so-called 
1  'essential  haematuria,"  without  a  lesion  in  the  kid- 
ney and  without  any  accompanying  pain.  Haema- 
turia,  therefore,  gives  rise  to  pain  only  when  other 
underlying  factors  are  present.  The  most  impor- 
tant of  these  is  the  presence  of  blood  coagula 
(malignant  tumors,  ulcerative  erosions  of  renal 
capillaries,  as  in  tuberculosis  of  the  papilla,  etc.). 
The  clots  in  these  cases  produce  the  same  patholog- 
ical condition  in  the  ureters  as  calculi,  and  occa- 
sionally cause  obstruction.  In  addition  to  this,  sud- 
den profuse  bleeding  may  cause  severe  distention 
and  in  this  way  give  rise  to  paroxysmal  pains. 
It  is  a  general  fact  that  under  suitable  conditions 
bleeding  into  hollow  muscular  organs  may  by  acute 
distention  give  rise  to  paroxysmal  pains.  The 
writer  has  seen  one  case  at  autopsy  in  which  bleed- 
ing had  taken  place  into  the  stomach  from  an 
cesophageal  vein.  In  this  case  severe  paroxysmal 
pains  in  the  epigastrium  had  occurred. 

A  true  kidney  pain,  that  is,  nephralgia  in  the  true 
sense  of  the  word,  is  occasionally  caused  by  bleeding 
from -vascular  tumors  of  the  kidney,  by  "  essential 
haematuria,"  or  by  acute  exacerbations  of  chronic 
nephritis ;  such  pains  may  be  due  either  to  distention 
by  the  haemorrhage  or  to  acute  congestion. 


272  PAIN 

URINARY  BLADDER. 

The  chief  characteristic  of  pain  in  the  bladder 
is  the  direct  relation  which  it  has  to  the  function 
of  the  organ,  that  is,  urination.  The  problem  of 
diagnosis  is  simpler  by  far  in  this  organ  than  in 
any  of  the  other  hollow  muscular  organs,  since 
pathological  changes  in  micturition  can  be  closely 
observed  by  both  patient  and  physician.  The 
mechanism  of  the  pain,  therefore,  can  be  more  ex- 
actly studied,  and  the  conditions  prevalent  here  can 
serve  to  throw  light  upon  similar  pains  occurring 
in  the  gall-bladder  and  stomach. 

The  conditions  which  give  rise  to  bladder  pains 
are  the  following: 

1.  CATARKHAL  AND  ULCERATIVE  CHANGES  IN  THE 
Mucous  MEMBRANES  OF  THE  BLADDER  AND  THE  URE- 
THRA.— These  are  chiefly  caused  by  acute  and  chronic 
forms  of  cystitis  following  urethral  infections,  in- 
flammatory conditions  due  to  calculi,  foreign  bod- 
ies,  tuberculosis,   neoplasms,   etc.    Urethral   stric- 
tures and  enlargement  of  the  prostate,  benign  or 
malignant,  are  important  in  that  they  predispose  to 
cystitis. 

2.  PERIVESICAL      INFLAMMATIONS.  —  These     are 
chiefly  diseases  of  the  female  genitals  and  diseases 
of  neighboring  parts  of  the  intestine  (rectum  and 
appendix). 

The  pain  is  often  directly  related  to  the  contrac- 
tion of  the  bladder  muscle  and  reaches  its  maximum 
at  the  height  of  contraction,  that  is,  during  the  end 
of  micturition  and  immediately  after  it. 


URINARY  SYSTEM  AND   SPLEEN         273 

Distention  o-f  the  bladder  wall  whenever  sudden 
may  also  cause  great  pain.  This  is  closely  analo- 
gous to  conditions  existing  in  the  gastro-intestinal 
tracts  and  the  bile-ducts. 

The  localization  of  the  pain,  both  subjective  and 
objective,  corresponds  to  the  location  of  the  organ, 
occurring  behind  the  symphysis.  In  prostatic  dis- 
ease it  is  occasionally  located  in  the  pierineum.  Ra- 
diation occurs  along  the  urethra  and  into  the  glands, 
into  the  .testicles,  and  into  the  inguinal  regions. 
Sometimes  the  pain  radiates  into  the  anus  and  the 
perineum.  When  this  happens  it  may  be  explained 
by  the  common  innervation  of  these  regions  by  the 
sacral  plexus. 

Reflexly  radiation  may  occur  upwards  into  the 
hypochondriac  regions,  downward  into  both  thighs, 
and  into  the  regions  innervated  by  the  sciatic  and 
the  anterior  crural  nerves.  This,  for  instance,  is 
the  case  in  prostatic  tumors. 

It  must  not  be  forgotten  that  in  rare  instances 
prostatic  tumors  may  occur  without  pain.  The  gen- 
eral condition  of  the  nervous  system  seems  to  have 
great  bearing  upon  this  feature. 

As  we  have  said,  bladder  contraction  is  the  most 
important  factor  in  producing  the  pain.  The  more 
forcibly,  therefore,  this  contraction  occurs  (as  in 
stricture,  enlargement  of  the  prostate,  and  calculi), 
and  the  more  severe  the  inflammation  of  the  mucous 
membrane,  the  more  violent  will  be  the  attacks.  In 
cases  where  the  mucous  membrane  of  the  bladder 
itself  is  intact,  and  the  pain  is  due  only  to  tugging 

18 


274  PAIN 

on  the  perivesical  adhesions,  the  attacks  are  never 
very  severe. 

Jarring  and  sudden  changes  of  position,  when 
they  have  any  relation  to  the  pain  at  all,  point 
toward  the  existence  of  calculi.  It  is  always  neces- 
sary to  examine  by  palpation  above  the  symphysis 
and  per  rectum  or  vaginam. 

Cold  drafts,  wetting  the  feet,  etc.,  may  reflexly 
give  rise  to  bladder  peristalsis. 

The  physical  and  chemical  properties  of  the  urine 
may  also  exert  marked  influence  upon  the  pain. 
Concentration  of  the  urine,  as  in  fever  with  serous 
exudation  (as  in  tuberculous  peritonitis)  or  in  con- 
sequence of  severe  perspiration,  may  give  rise  to 
pain  in  an  irritable  bladder.  Spicy  food  and  certain 
drugs,  such  as  urotropin,  in  large  doses,  give  rise 
to  similar  sensations. 

The  most  important  secondary  symptoms  to  be 
considered  are  pyuria  and  bacteriuria.  Whenever 
these  two  conditions  are  absent,  we  should  suspect 
calculi  or  perivascular  inflammations ;  haematuria, 
too,  for  obvious  reasons,  is  not  rare.  Whenever  this 
occurs,  together  with  pains  in  the  bladder,  a  vascu- 
lar origin  of  the  pain  is  most  likely.  Frequent  mic- 
turition is,  next  to  pyuria,  the  most  usual  of  the 
secondary  symptoms. 

The  fact  that  the  pains  are  usually  in  direct  rela- 
tion to  the  bladder  function,  makes  an  error  in  diag- 
nosis rather  rare ;  yet  it  is  well  to  remember  that  the 
symptoms  of  disease  of  the  bladder  itself  are  so 
similar  to  those  of  disease  of  the  prostate  and  pos- 


URINARY  SYSTEM  AND  SPLEEN         275 

terior  urethra,  that  a  separation  from  these  is  almost 
impossible  without  the  aid  of  objective  symptoms. 
Examination  of  the  prostate  is,  therefore,  essential. 

Differentiation  of  these  conditions  from  a'ttacks 
of  pain  which,  like  gastric  crises,  have  their  origin 
in  the  central  nervous  system,  may  be  neglected 
because  of  the  extreme  rarity  of  such  attacks. 

On  purely  theoretical  grounds,  we  may  say  that 
conditions  dependent  upon  the  nervous  system  would 
be  independent  of  micturition.  Sensitiveness  of  the 
bladder  upon  examination  per  vaginam  or  per  rec- 
tum would  point  to  organic  disease.  The  pains  occa- 
sionally radiate  into  the  rectum  and  are  in  direct 
relation  to  defecation.  This  occurs  chiefly  in  dis- 
eases of  the  prostate  and  in  vesical  calculi,  and  may 
lead  to  an  erroneous  diagnosis  of  intestinal  disease. 
Radiations  into  the  genitals  and  thighs  may  occa- 
sionally be  misconstrued  as  ureteral  colic.  Only 
careful  physical  examination  can  guard  us  against 
these  errors. 

In  the  section  on  true  kidney  pains,  we  called 
attention  to  the  fact  that  neoplasms  of  the  bladder 
may,  by  obstruction  to  the  ureters,  give  rise  to 
ureteral  colic  and  sensitiveness  of  the  kidneys  them- 
selves on  one  or  both  sides.  Conversely,  tubercu- 
lous disease  of  the  kidney  may  frequently  be  accom- 
panied by  the  subjective  symptoms  of  cystitis,  and, 
even  when  the  bladder  and  urethra  are  entirely  nor- 
mal, pains  may  be  produced  in  them  by  pressure 
upon  the  diseased  kidney. 


276  PAIN 

SPLEEN. 

Pathological  processes  in  the  spleen  often  give 
rise  to  pain  at  extremely  early  stages  of  their  de- 
velopment, and,  in  correspondence  with  the  position 
of  th^  organ,  such  pain  is  localized  in  the  left  hypo- 
chondrium.  Since  we  are  dealing  with  a  ductless 
gland  the  pains  produced  here  cannot  possess  the 
manifold  variety  of  those  occurring  in  organs  with 
muscular  ducts.  Here  there  are  but  two  factors  to 
be  considered: 

1.  Distention  of  the  spleen  capsule  with  enlarge- 
ment of  the  organ. 

2.  Inflammation    of    its.   peritoneal    coverings 
(perisplenitis). 

The  conditions  which  a-re  accompanied  by  pain 
in  the  spleen  are  chiefly: 

(a)  Myelogenous  Leukcemia. — In  this  condition 
the  pain  in  the  spleen  is  frequently  one  of  the  first 
symptoms.    Sudden  and  intense  pain  is  caused  by 
inflammation  of  the  capsule  with  or  without  the 
formation  of  infarcts.    Pseudoleukaemia  and  polycy- 
themia  also  give  rise  to  pain  in  the  spleen ;  chlorosis 
and  pernicious  anaemia  more  rarely. 

(b)  Cirrhosis    of   the   Liver. — Splenic   involve- 
ment is  most  frequently  found  in  cases  of  syphilitic 
cirrhosis,  and  in  such  cases  the  perisplenitis  goes 
hand  in  hand  with  the  existing  perihepatitis.    Many 
of  the  so-called  Banti's  cirrhoses  (hereditary  lues) 
come  under  this  heading.  Splenic  pains  occasionally 
accompany  Hanot's  cirrhosis,  but  are  hardly  ever 
present  in  the  atrophic  variety  of  Laennec. 


URINARY  SYSTEM  AND  SPLEEN         277 

(c)  Paroxysmal    Hamoglobinuria.— During    at- 
tacks of  paroxysmal  hsemoglobinuria  splenic  pains 
may  occasionally  be  noticed. 

(d)  Infectious  Processes.— The  infectious  proc- 
esses which  are  most  commonly  accompanied  by 
splenic  pain  are  typhoid  fever  and  malaria. 

Occurring  in  the  left  axillary  line,  the  splenic 
pains  in  these  diseases  are  often  erroneously  re- 
garded as  evidences  of  a  pleurisy  or  a,  lower  lobar 
pneumonia.  This  error  is  more  easily  made  since 
in  cases  with  splenic  swelling  fine  crepitant  rales 
often  occur  along  the  line  of  separation  between  the 
lung  and  the  spleen,  due  to  atelectasis  of  the  margin 
of  the  lung. 

Whenever  we  are  attempting  to  obtain  a  history 
of  a  previous  attack  of  malaria,  it  is  well  to  inquire 
whether  at  the  time  of  the  chill  there*  were  pains  in 
the  splenic  region.  Sharp  pains  along  the  right 
costal  border  often  occur  together  with  these  and 
are  due  to  hepatic  swelling. 

Pain  on  palpation  along  the  left  costal  border 
in  a  patient  who  is  running  a  temperature  and  in 
whom  we  can  exclude  pleurisy  and  subphrenic  ab- 
scess, usually  points  to  marked  swelling  of  the 
spleen. 

(e)  Heart  Disease. — In  patients  with  heart  le- 
sions (mitral  stenosis,  etc.)  acute  pains  occurring  in 
the  region  of  the  spleen  or  sensitiveness  in  the  inter- 
costal spaces  corresponding  with  the  position  of  the 
spleen,  should  always  arouse  the  suspicion  of  splenic 
infarction.     This  suspicion  is  strengthened  by  symp- 
toms of  emboli  in  other  regions  (renal  arteries,  etc.). 


278  PAIN 

Progressive  increase  of  the  pain  in  a  case  of 
recent  endocarditis  points  to  the  possibility  of  sec- 
ondary abscess  formation. 

Since  the  position  and  size  of  the  spleen  are 
subject  to  great  variation  in  the  different  patho- 
logical conditions,  it  is  natural  that  the  exact  topog- 
raphy of  the  pains  should  show  corresponding  varia- 
tion. In  all  cases,  however,  the  pain  is  felt  in  the 
left  side  along  the  lower  thoracic  and  upper  abdomi- 
nal regions.  Whenever  pain  occurs  in  this  situation 
examinations  should  be  made  for  sensitiveness  under 
the  left  costal  border  and  in  the  lower  intercostal 
spaces  from  the  eighth  downward. 

Splenic  tumors  may  occasionally  give  rise  to 
dorsal  pain,  especially  after  prolonged  lying  on  the 
back.  When  the  spleen  is  so  large  that  it  sinks  for 
any  considerable  distance  below  the  costal  border, 
as  in  leukaemia,  for  instance,  it  is  important  to  deter- 
mine whether  the  sensitiveness  is  of  diffuse  or  cir- 
cumscribed nature.  Circumscribed  pains  of  this  de- 
scription are  occasionally  due  to  splenic  infarct  or 
local  perisplenitis. 

Every  now  and  then  pain  occurs  along  the  angle 
of  the  left  scapula  or  between  the  shoulder  blades. 
In  some  cases  there  is  marked  pain  in  the  left  shoul- 
der, often  so  severe  that  motion  of  the  left  arm 
becomes  difficult. 

Such  radiations  may  occur  spontaneously  or  may 
be  caused  by  sudden  stooping,  trauma,  or  lying  on 
the  left  side.  In  such  cases  localized  points  of  sensi- 
tiveness can  be  determined.  The  most  common  situa- 


URINARY  SYSTEM  AND   SPLEEN         279 

tions  of  these  are  over  the  acromion  process  and  at 
the  junction  of  the  external  and  middle  third  of  the 
upper  edge  of  the  trapezius  muscle.  The  conditions 
prevalent  here  are  exact  counterparts  of  those  exist- 
ing in  the  right  shoulder  with  perihepatitis. 

The  quality  of  the  pain  is  usually  described  by 
the  patient  as  stabbing  or  tearing.  Mechanical 
motions  often  initiate  attacks  of  pain.  The  mechani- 
cal factors  to  be  considered  are : 

1.  Compression  of  the  organ  produced  by  stoop- 
ing, quick  turning  to-  the  left  of  the  trunk  upon  the 
hips,  lifting  of  the  left  arm,  etc.    In  contrast  to  this, 
relaxation  of  the  abdominal  muscles  relieves   the 
pain,  and  in  consequence  patients  often  walk  in  a 
stooping   position.     Palpation   and   percussion   in- 
fluence the  pain  in  a  similar  way. 

2.  Change  of  Position  of  the  Organ. — Lying  on 
the  left  or  right  side  usually  produces  pain  and  a 
sensation  of  tension  in  the  left  side.    This  is  espe- 
cially the  case  when  the  stomach  is  empty,  the  full 
stomach  acting  as  a  sort  of  cushion.    For  obvious 
reasons  deep  breathing  will  cause  pain  when  peri- 
splenitis  is  present. 

3.  Sudden  Jarring.— All  varieties  of  jarring  will 
give  rise  to  pain,  prolonged  walking,  running,  riding 
in  a  carriage,  hiccoughing,  sneezing,  etc. 

Occasionally,  besides  the  mechanical  means  of 
starting  the  pain,  digestive  conditions  will  influence 
it.  Abnormally  large  quantities  of  food  will  give 
rise  to  pain  by  causing  secondary  hyperaemia  of  the 
organ.  This  is  especially  the  case  when  inflamma- 


280  PAIN 

tory  adhesions  exist  between  the  stomach,  and  the 
spleen. 

The  influence  of  drugs  on  the  diagnosis  is  not 
negligible  since  the  pain  caused  by  increased  tension 
of  the  capsule  is  diminished  by  all  those  drugs  which 
produce  a  diminution  in  the  size  of  the  spleen.  Such 
are  arsenic  and  quinine. 

The  most  frequent  secondary  symptoms  occur- 
ring with  splenic  pain  are  increased  size  of  the 
spleen  as  detected  by  percussion  and  palpation,  fric- 
tion sounds  produced  by  perisplenitis,  and  a  systolic 
murmur  heard  over  the  splenic  vessels. 

The  most  important  condition  to  be*  considered 
in  differential  diagnosis  is  pleurisy.  Differentiation 
is  especially  difficult  in  the  case  of  acute  disease, 
such  as  malaria  and  typhoid  fever.  The  pains  in 
these  cases  are  felt  in  the  axillary  and  intercostal 
regions.  They  are  dependent  upon  deep  breathing. 
Lying  on  the  left  side  is  usually  painful  and  occa- 
sionally produces  a  cough.  There  are  fine  crepitant 
rales  over  the  area  of  pain,  due  to  atelectasis  caused 
by  the  large  size  of  the  spleen.  By  these  signs  one 
is  led  to  suspect  pleurisy  or  early  pneumonia  and  to 
forget  the  fact  that  the  pain  may  be  due  to  an 
increased  tension  upon  the  splenic  capsule. 

In  the  same  way  infarcts  of  the  lung  and  spleen 
may  often  be  mistaken  for  one  another  in  patients 
with  heart  disease.  In  such  cases  examination  of 
the  spleen  reveals  its  sensitiveness.  Much  informa- 
tion, too,  can  be  gathered  by  careful  examination  of 
the  intercostal  spaces  in  the  axillary  line  in  order  to 


URINARY  SYSTEM  AND   SPLEEN         281 

determine  whether  or  not  they  are  sensitive.  When 
the  condition  is  one  of  splenic  pain  the  sensitiveness 
in  the  intercostal  spaces  is  limited  pretty  well  to 
the  area  of  dulness  of  the  organ. 

Splenic  pains  are  occasionally  misinterpreted  as 
arising  in  the  stomach,  since,  as  has  already  been 
mentioned,  the  taking  of  food  often  increases  the 
pain  or  initiates  an  attack.  In  a  general  way  this 
can  be  avoided  by  remembering  that  in  splenic  con- 
ditions the  quantity  of  the  food,  entirely  independent 
of  its  quality,  gives  rise  to  the  attack.  In  cases 
where  radiation  of  the  pain  into  the  left  shoulder 
takes  place,  a  diagnosis  of  articular  rheumatism 
is  occasionally  made.  The  absence,  however,  of 
change  in  the  joint  itself,  the  entire  freedom  of 
motion,  and  the  determination  of  the  above-men- 
tioned points  of  tenderness  (at  the  acromion  and 
along  the  border  of  the  trapezius)  will  aid  in  the 
differentiation. 


CHAPTER  IX. 

RESPIRATORY  AND  CIRCULATORY  SYSTEMS. 

THE    LUNGS. 

PAIN  may  unquestionably  occur  in  the  trachea 
and  the  two  main  bronchi.  At  any  rate,  it  is  cus- 
tomary to  interpret  the  retrosternal  pain  occurring 
almost  regularly  with  acute  bronchitis  during  the 
stage  of  dryness  and  congestion,  as  emanating  from 
these  organs.  On  the  other  hand,  distinctive  proc- 
esses which  involve  the  air  vesicles  of  the  lung,  such 
as  lymphosarcoma  and  pulmonary  abscess,  may  run 
their  entire  course  without  any  pain.  It  is,  there- 
fore, perfectly  safe  to  claim  that  lesions  occurring 
in  the  parenchyma  of  the  lung  itself  do  not  give  rise 
to  pain. 

The  production  of  pain  in  disease  of  the  lung  is, 
therefore,  dependent  entirely  upon  involvement  of 
the  pleura.  This,  of  course,  is  most  frequently  of 
an  inflammatory  nature. 

These  simple  facts  give  the  key  to  the  compre- 
hension of  all  pains  which  occur  in  connection  with 
pulmonary  disease  and  permit  us  to  understand  their 
nature  and  radiations. 

It  must  not  be  forgotten  that  the  visceral  and 
parietal  pleura  are  in  very  intimate  relation  with 
many  nerves  (brachial  plexus,  intercostal  and 
phrenic  nerves),  and  that  they  likewise  have  close 
anatomical  relation  to  the  intercostal  muscles  and 

282 


RESPIRATION  AND  CIRCULATION        283 

diaphragm.  For  these  reasons  the  occurrence  of 
secondary  neuralgias  and  myalgias  is  more  than 
likely. 

Since,  therefore,  the  pains  accompanying  all  the 
various  lesions  of  the  lung  are  dependent  upon  the 
inflammatory  pleurisy,  it  is  simplest  to  describe  them 
all  together  in  a  general  way,  pointing  out,  as  we 
proceed,  the  various  features  of  differentiation. 

As  regards  localization,  these  pains  correspond 
almost  exactly  with  the  situation  of  the  pleural  in- 
flammation, and  the  greatest  intensity  of  the  pain, 
both  subjectively  and  objectively,  coincides  with  the 
most  marked  auscultatory  sounds. 

Disease  of  the  pleura  over  the  upper  lobes  (tu- 
berculosis and  neoplasms)  evidences  itself  chiefly 
by  pain  in  the  region  of  the  shoulder,  in  the  supra- 
and  intraclavicular  fossae  and  in  the  supraspinous 
regions.  These  pains  should  be  looked  for  espe- 
cially in  cases  in  which  we  suspect  early  tuberculosis. 

The  pains  in  the  shoulders,  which  so  often  occur 
in  tuberculous  patients  at  the  very  beginning  of  the 
disease,  are  probably  caused  in  most  cases  by  the 
adhesions  at  the  apex  of  the  lung  found  so  fre- 
quently at  autopsy.  The  inflammatory  process  oc- 
curring along  the  summit  of  the  pleura  may  involve 
secondarily  the  brachial  plexus  and  the  upper  inter- 
costal nerves.  For  this  reason  tenderness  along  the 
brachial  plexus  and  along  the  upper  intercostal 
spaces  is  frequently  present  in  cases  of  tuberculosis 
and  is  in  many  cases  one  of  the  first  symptoms.  The 
point  of  tenderness  which  was  mentioned  as  a  reflex 


284  PAIN 

symptom  of  hepatic  and  splenic  enlargements  (at  the 
junction  of  the  outer  and  middle  thirds  of  the  upper 
border  of  the  trapezius  muscle)  can  occasionally  be 
demonstrated  in  these  cases  as  well. 

It  need  hardly  be  mentioned  that  carcinoma  de- 
veloping in  the  apex  of  the  lung  might  give  rise  to 
secondary  injury  of  the  brachial  plexus  and  conse- 
quent neuralgia  in  the  arm. 

When  the  pleura  are  diffusely  diseased,  as  in 
pleurisy  and  pyopneumothorax,  the  subjective  pain 
and  tenderness  often  fail  to  show  a  correspondingly 
diffuse  character.  On  the  contrary,  they  are  usually 
located  in  the  axilla  or  in  front,  rarely  posteriorly, 
and,  when  this  does  occur,  only  in  the  last  intercostal 
spaces. 

This  is  due  to  a  number  of  causes.  Chief  among 
these,  probably,  is  the  fact  that  the  respiratory 
excursions  of  the  lung  reach  their  greatest  develop- 
ment at  the  bases  and  thus  the  greatest  motion  of  the 
pleural  leaves  upon  each  other  takes  place  in  the 
costophrenic  sinuses. 

Whatever  the  reason  may  be,  the  facts  remain 
that  pains  which  arise  in  the  pleura  are  frequently 
found  only  in  the  axillary  line,  and  that  sensitive- 
ness to  pressure  is  limited  to  the  area  below  the  fifth 
intercostal  space.  The  latter  fact  may  in  part  be 
due  to  the  absence  of  a  muscular  covering  over  these 
spaces. 

Occasionally,  cases  of  diffuse  pleurisy  and 
pleuropneumonia  of  the  lower  lobe  occur,  in  which 
the  tenderness  is  limited  to  the  abdomen,  just  below 


RESPIRATION  AND  CIRCULATION       285 

the  costal  border.  This  may  lead  to  errors  in  diag- 
nosis. In  such  cases  upward  pressure  in  the  flank, 
hypogastrium,  and  (in  right-sided  cases)  even  the 
ileocaecal  region,  will  give  rise  to  pain. 

This  peculiar  distribution  of  the  pain  is  probably 
due  to  involvement  of  the  diaphragmatic  pleura. 
The  diaphragm  forms  a  sort  of  bridge  across  which 
the  thoracic  pain  enters  the  abdominal  regions. 
Even  the  subjective  pain  in  pleurisy  may  in  a  good 
many  cases  be  localized  along  the  costal  border. 

One  of  the  favorite  seats  of  pain  in  left-sided 
pleurisy  is  the  region  of  the  heart  apex.  This  may 
be  due  to  the  fact  that  during  systole  the  apex  of 
the  heart,  by  friction,  increases  the  inflammation 
and,  therefore,  in  spite  of  the  diffuse  nature  of  the 
pleurisy,  may  give  rise  to  circumscribed  pain. 

Retrosternal  position  of  the  pain  is  rare.  It  does 
occur,  however,  and  is  usually  associated  with  in- 
flammation of  the  mediastinal  pleura  and  with  le- 
sions of  the  mediastinal  lymph  nodes.  In  such 
cases,  however,  it  would  also  be  necessary  to  think 
of  pericarditis. 

The  pains  occurring  in  the  interscapular  space  in 
pulmonary  tuberculosis  may  also  occur  in  diffuse 
pleurisy. 

The  quality  of  the  pain  is  rarely  characteristic, 
and  it  is  very  difficult  to  differentiate  it  from  that 
of  intercostal  neuralgia  or  myalgia.  As  a  general 
rule  we  may  say  that  the  pain  is  of  a  sharp  and 
stabbing  character. 


286  PAIN 

Special  characteristics  of  the  pain  are  present 
only  in  rapidly  developing  pneumothorax,  where  the 
pain,  just  like  the  pain  accompanying  perforation 
of  the  gut  into  the  peritoneum,  is  extremely  acute 
and  diffuse,  and  involves  the  entire  half  of  the 
thorax.  Added  to  this  there  is  a  peculiar  sensation 
of  internal  soreness  or  tearing.  Similar  pain,  how- 
ever, may  be  observed  in  subpleural  cavities  without 
perforation,  and  the  confusion  may  be  increased  by 
the  occurrence  of  collapse.  Similar  acute  attacks 
of  pain  occasionally  accompany  the  perforation  of 
an  empyema. 

The  factors  most  markedly  influencing  the  pleural 
pain  are: 

1.  Pressure. — There  are  cases  of  pleurisy  in  which 
even  a  light  touching  of  the  skin  of  the  thorax  with 
a  needle,  with  the  bare  hand,  or  with  the  bed-cover, 
may  give  rise  to  the  most  intense  pain  (empyema). 
On  the  other  hand,  there  may  be  all  transitions  from 
this  extreme  condition  of  sensitiveness  to  an  absolute 
lack  of  pain.  The  factor  determining  this,  of  course, 
is  the  degree  of  acuteness  and  severity  of  the  inflam- 
matory process.  The  condition  is  unquestionably 
analogous  to  a  similar  condition  in  the  peritoneum. 
The  area  of  sensitiveness  to  pressure  is  usually  much 
more  diffuse  than  the  area  of  subjective  pain.  In 
every  individual  case  it  is  important  to  observe  the 
zone  of  sensitiveness  and  to  observe  its  increase  or 
decrease  during  the  course  of  the  disease.  In 
pleuropulmonary  disease  the  pain  which  occurs  in 
the  abdomen  is  hardly  ever  spontaneous  and  is  dis- 


RESPIRATION  AND  CIRCULATION       287 

covered  only  by  examination.  While  the  dia- 
phragm, as  mentioned  above,  is  usually  the  means 
of  transmission  of  such  pain  to  the  abdomen,  in 
right-sided  lesions  it  is  always  necessary  to  consider 
the  possibility  of  secondary  liver  pain  due  to  peri- 
hepatitis  or  hepatic  congestion. 

Sensitiveness  to  pressure  is  limited  chiefly  to  the 
axillary  and  anterior  aspects  of  the  thorax,  and 
favors  the  lower  intercostal  spaces.  This  is  true 
at  any  rate  of  cases  of  acute  pleurisy.  In  apical 
tuberculosis  when  pleural  adhesions  are  developing, 
the  sensitiveness  to  pressure  is  usually  localized  in 
the  subclavicular  or  subspinous  fossae,  and  in  the 
upper  anterior  intercostal  spaces.  The  same  is  true 
of  cavity  formation  in  apical  tuberculosis.  These 
objective  pains  are  of  especial  importance  for  early 
diagnosis,  since  they  may  appear  when  subjective 
pains  are  still  absent. 

The  pain  may  be  definitely  ascribed  to  a  pleural 
lesion  whenever  sensitiveness  to  pressure  and  crepi- 
tant  rales  are  found  in  one  and  the  same  spot.  It 
is  occasionally  difficult  to  exclude  intercostal  neural- 
gia. (For  a  discussion  of  this  refer  to  the  chapter 
on  the  subject.) 

"Whenever  pressure  upon  the  rib  itself  is  painful, 
it  is  obvious  that  (having  excluded  periostitis)  we 
must  assume  the  existence  of  a  secondary  intercostal 
neuralgia. 

In  pericarditis  the  pain  seems  to  be  chiefly  sub- 
jective, modified  little,  if  at  all,  by  pressure;  it  is 


288  PAIN 

located  more  anteriorly  and  retrosternally,  rather 
than  in  the  axilla. 

2.  Position  and  Motion. — Lying  upon  the  dis- 
eased side  causes  pain  by  direct  pressure.    For  a 
consideration  of  this  position,  therefore,  the  remarks 
made  in  the  preceding  paragraphs  may  be  consulted. 

When  the  patient  lies  on  the  healthy  side,  how- 
ever, different  conditions  prevail.  In  this  position 
the  patient  frequently  suffers  great  distress,  which 
gives  him  the  impression  that  the  pain  is  drawing 
over  into  the  healthy  side. 

Such  sensations  are  chiefly  present  in  cases  of 
pleural  exudate,  more  rarely  with  cavities,  and  must 
be  ascribed  to  a  shifting  of  the  organs  in  the  media- 
stinum. When  the  patient  lies  upon  the  healthy 
side,  also,  the  work  of  the  diseased  side  is  increased 
and  the  pain  occurring  with  respiration  is  neces- 
sarily greater.  In  some  rare  cases  lying  upon  the 
abdomen  relieves  the  pain.  (This  was  the  case  in 
a  patient  with  pleural  pain  in  the  neighborhood  of 
the  heart  apex.) 

The  pain  is  increased  when  the  patient  is  upright 
and  his  head  is  bent  forward.  This  is  due  to  the 
increased  costal  respiration.  Stooping  occasionally 
gives  rise  to  pain. 

3.  Inspiration  and  Expiration. — Coughing  and 
sneezing  come  under  this  heading,  since  all  these 
forcible  movements  in  the  pleura  presuppose  an 
analogous  action  of  the  muscles  of  inspiration. 

In  cases  of  pyopneumothorax,  however,  there  is 
no  increase  of  the  pain  with  deep  inspiration.  This 


289 

is,  in  part,  due  to  immobilization  of  the  correspond- 
ing half  of  the  thorax,  and  in  part  to  a  lack  of  con- 
tact between  the  leaves  of  the  pleura. 

Whenever  a  chill  or  any  febrile  movement  is  fol- 
lowed by  sharp  pain  in  the  axillary  regions,  the  diag- 
nosis of  pleural  pain  is  obvious,  and  the  first  sus- 
picions are,  of  course,  of  pneumonia  or  pleurisy. 
Yet  it  is  important  to  remember  that  occasionally 
a  malarial  chill  is  accompanied  by  pain  in  the  lower 
intercostal  regions  and  in  the  axillary  portions  of 
the  left  chest.  These  pains  we  have  already  referred 
to  as  emanating  from  the  spleen  and  due  to  tension 
in  the  splenic  capsule.  The  presence  of  herpes  and 
the  fine  crepitant  rales  of  atelectasis  at  the  base  of 
the  left  lung  (pushing  upward  of  the  diaphragm 
by  the  enlarged  spleen)  increase  the  possibility  of 
error. 

Whenever  pains  occur  along  the  lower  portions 
of  the  thorax  it  is  wise  to  think  of  the  subdiaphrag- 
matic  organs  and  their  appendages. 

The  sensitiveness  which  accompanies  acute  right- 
sided  pneumonia  and  pleurisy  is  occasionally  local- 
ized in  the  ileocsecal  region.  This  is  especially  fre- 
quent in  children  and  may  lead  to  a  false  diagnosis 
of  appendicitis. 

The  interpretation  of  thoracic  pains  is  far  more 
difficult  in  chronic  conditions  which  run  their  course 
without  fever.  In  such  cases  it  is  always  difficult 
to  decide  whether  the  pains  have  a  pleural  origin 
(such  as  the  chronic  pleural  adhesions  so  often 
found  in  tuberculous  individuals)  or  whether  we  are 

19 


290  PAIN 

dealing  with  an  absolutely  independent  neuralgia 
or  myalgia. 

When  there  have  been  very  severe  coughing 
spells  it  is  always  well  to  think  of  myalgia  due  to 
fatigue  (analogous  to  the  pains  in  the  calves  of  the 
legs  following  long  walking  tours).  It  is  perfectly 
obvious  that  the  pain  due  to  a  muscular  or  nervous 
cause  may  be  initiated  by  the  same  factors  that  give 
rise  to  pleural  pain  (respiration,  etc.).  On  the  one 
hand,  there  may  be  absolutely  no  physical  signs  in 
the  chronic  adhesive  pleurisies;  on  the  other,  the 
pain  in  intercostal  neuralgia,  by  limiting  respiratory 
excursion,  may  lead  to  secondary  atelectasis  with 
crepitant  rales.  It  is  very  important,  therefore,  to 
determine  whether  the  lower  border  of  the  lung 
moves  properly  with  respirations.  Examination  of 
the  domes  of  the  diaphragm  with  X-ray  is  also 
advisable. 

Careful  differential  diagnosis  in  all  these  cases 
is  almost  impossible,  but  there  are  a  number  of 
points  which  may  be  of  great  help. 

1.  One-sided  objective  or  subjective  pain,  local- 
ized in  the  axilla,  points  with  great  probability  to  a 
pleural  origin. 

2.  The  same  is  true  of  one-sided  pain  limited 
to  the  apex  of  the  lung,  especially  when  this  is  accom- 
panied by   ana?mia,   emaciation   and  neurasthenia, 
even  when  the  physical  examination  of  the  lung  is 
negative. 

3.  Careful  investigation  of  the  previous  history 
must  be  made  as  regards  overexertion  of  the  muscles 


RESPIRATION  AND  CIRCULATION       291 

of  the  arm  or  chest,  and  exposure  to  draughts.  In- 
quiry must  be  made  as  to  rheumatic  or  neuralgic 
tendencies,  and  symptoms  of  these  diseases  in  other 
parts  of  the  body  must  be  looked  for.  These,  when 
present,  point  toward  neuralgic  or  myalgic  origin 
of  the  pain. 

4.  Whenever  lying  on  the  diseased  side  causes 
coughing,  it  is  obvious  that  the  pain  emanates  from 
the  pleura. 

In  the  preceding  section  we  have  differentiated 
pleural  pains  from  those  not  localized  in  the  pleura, 
but  we  have  paid  no  attention  to  the  differentiation 
of  the  specific  pleural  lesions  which  may  produce 
such  pains. 

In  cases  in  which  there  is  unquestionably  a  lesion 
of  the  lungs  and  the  pleura,  the  exact  nature  of  the 
lesion  can  be  determined  only  by  careful  analysis 
of  the  pain.  The  very  absence  of  pain  in  such  cases 
is  of  great  diagnostic  significance.  Thus,  whenever 
large  areas  of  dullness  occur  entirely  without  sub- 
jective or  objective  pains,  although  it  is  not  possible 
absolutely  to  exclude  inflammatory  pleurisy,  never- 
theless it  is  advisable  to  think  of  neoplasms,  echino- 
coccus,  dermoid  cysts,  and  pulmonary  abscesses, 
processes  which  are  not  necessarily  accompanied  by 
severe  inflammations  along  the  pleura  and  may 
therefore  develop  with  little  or  no  pain.  Dullness 
along  the  base  of  the  lung  without  sensitiveness  over 
the  lower  intercostal  spaces  points  to  the  existence 
of  a  subphrenic  abscess. 


292  PAIN 

Symptoms  of  pneumonia  with  infraclavicular 
pains  should  lead  us  to  think  immediately  of  a  begin- 
ning apical  pneumonia. 

Analysis  of  the  pain  often  aids  in  differentiating 
a  cavity  from  a  pneumothorax,  a  differential  diag- 
nosis which  is  sometimes  extremely  difficult.  This  is 
true,  too,  of  cases  in  which  we  are  trying  to  decide 
whether  a  sudden  profuse  expectoration  is  due  to 
the  evacuation  of  a  cavity  or  to  the  rupture  of  a  sac- 
culated  empyema.  In  the  latter  case  the  act  of 
rupture  is  accompanied  by  intense  pains  and  the 
sensitiveness  along  the  intercostal  spaces  corre- 
sponding to  the  sacculation  is  immediately  dimin- 
ished, just  as  after  the  incision  of  an  abscess. 

Cavities,  on  the  other  hand,  since  they  are  more 
centrally  situated,  hardly  ever  lead  to  much  sensi- 
tiveness of  the  corresponding  costal  spaces,  and  give 
rise  to  no  attacks  of  pain  during  the  act  of  evacua- 
tion. 

AORTA. 

The  phenomena  which  have  occupied  our  atten- 
tion in  the  preceding  chapters,  pains  occurring  in 
the  alimentary  tract,  liver  and  kidney,  have  had 
three  fundamental  factors  in  common: 

1.  Local  spasm  in  a  hollow  muscular  organ. 

2.  Local  distention  of  its  capsule  or  walls. 

3.  Inflammatory  processes  in  their  serous  cover- 
ings. 

The  second  and  third  of  these  factors,  as  we  have 
seen,  may  combine  in  many  of  these  conditions. 


RESPIRATION  AND  CIRCULATION       293 

It  is  beyond  doubt  that  diseases  of  the  thoracic 
or  abdominal  aorta  (such  as  aortitis  or  aneurysm) 
may  give  rise  to  pain.  The  question  naturally 
arises,  therefore,  whether  the  mechanism  of  this 
pain  is  entirely  a  new  one,  or  whether  it  is  caused 
by  factors  similar  to  those  occurring  in  the  other 
conditions. 

Anatomically,  the  severe  inflammations  of  the 
aorta  may  involve  the  vessel  wall  in  toto  or  in  part. 
Such  inflammatory  conditions  are  comparable  with 
the  third  factor  given  above. 

It  is  a  matter  of  fact,  too,  that  added  to  the  in- 
flammatory processes  constant  or  paroxysmal  over- 
stretching of  the  inflamed  aortic  wall  may  occur 
(by  aneurysm  or  increased  tension).  The  condition 
of  tension  may  be  chronic  (arteriosclerosis),  or  there 
may  be  a  sudden  increase  of  pressure  with  increased 
action  of  the  heart  and  increased  resistance  in  the 
capillaries  (vasomotor  disturbances,  such  as  cramps 
or  paresis).  These  conditions  are  comparable  to 
those  mentioned  under  the  second  group  (see  above) 
which  dealt  with  overdistention. 

Since,  therefore,  we  have  the  two  elementary 
factors,  two  and  three  actually  present  and  fre- 
quently acting  in  unison,  the  question  arises  whether 
the  sympathetic  nerve  endings  embedded  in  the  vas- 
cular wall  are  capable  of  conveying  painful  sensa- 
tions. This  question  can  be  answered  decidedly  in 
the  affirmative.  Definite  affirmative  evidence  is 
offered  by  the  pressure  pain  which  is  found  in  in- 
flammatory processes  of  the  peripheral  arteries 


294  PAIN 

(carotid,  etc.).  Similar  support  for  this  opinion 
is  found  in  the  tenderness  which  unquestionably 
occurs  in  the  suprasternal  fossa  over  the  aortic  arch 
or. over  the  abdominal  aorta,  in  conditions  of  chronic 
aortic  inflammation. 

The  etiological  factors  in  aortic  pain  are,  there- 
fore :  1.  Inflammatory  and  degenerative  processes  in 
the  aortic  wall.  2.  A  condition  of  hyperaesthesia 
of  the  sympathetic  network  embedded  in  the  aortic 
wall.  3.  Chronic  or  temporary,  local  or  general,  in- 
crease of  internal  pressure  in  the  aorta. 

These  factors  need  not  necessarily  occur  in  com- 
bination, but  when  present  in  combination,  of  course, 
produce  the  most  favorable  conditions  for  the  occur- 
rence of  pain.  Thus,  a  priori,  we  may  assume  that 
two  and  three  together  would  be  sufficient  to  produce 
attacks  of  pain  in  individuals  of  a  neuropathic  tem- 
perament. 

The  fact  that  occasionally  aortic  processes  may 
run  their  course  without  pain  does  not  contradict 
these  statements.  One  might  just  as  well  say  that 
articular  inflammation  is  not  the  cause  of  the  pains 
of  arthritis  because  occasionally  a  case  of  arthritis 
runs  its  course  without  pain. 

The  conditions  of  primary  importance  in  this  con- 
nection are  usually  spoken  of  as  "angina  pectoris." 
The  name  is  purely  symptomatic  and  has  no  relation 
to  the  etiology. 

The  mechanism  which  gives  rise  to  the  pain  in 
these  cases  may  be  subject  to  considerable  variation. 
The  anatomical  basis  underlying  the  pains  of  angina 


RESPIRATION  AND  CIRCULATION        295 

pectoris  (excluding,  of  course,  all  those  cases  which 
are  essentially  neuralgic)  seems  to  consist  of  two 
main  features.  These  are  disease  of  the  wall  of  the 
aorta  itself  (the  ascending  aorta  and  arch  espe- 
cially) and  disease  of  the  coronary  arteries. 

There  can  be  little  doubt  about  the  production 
of  pain  by  disease  of  the  aortic  wall.  Such  pain  may 
be  of  many  kinds,  and  angina  pectoris  is,  in  a  way, 
only  a  special  form  of  aortic  pain.  Chronic  dilata- 
tion of  the  ascending  aorta  or  of  the  aortic  arch  fre- 
quently gives  rise  to  constant  pain  which,  in  its 
localization  and  radiation,  is  entirely  similar  to  that 
which  characterizes  attacks  of  angina  pectoris. 

We  have  already  called  attention  to  the  fact  that 
the  general  etiology  of  the  aortic  pains  stands  in 
close  analogy  to  the  pains  produced  in  other  organs. 
Quite  frequently  severe  attacks  of  angina  pectoris 
can  be  explained  at  autopsy  by  gross  pathological 
lesions  either  of  the  coronary  arteries  themselves  or 
of  their  mouths  (usually  narrowing  of  the  entrances 
to  the  arteries  by  atheroma  or  vegetations).  Etio- 
logical  relationship  unquestionably  exists  between 
these  lesions  and  the  attacks.  Nevertheless,  in  many 
cases  there  is,  at  the  same  time,  gross  pathological 
change  of  the  aorta  itself,  and  it  is  hard  to  decide 
which  of  the  symptoms  are  due  to  the  aortic  lesions 
and  which  are  more  directly  referable  to  the  disease 
of  the  coronary  arteries.  Generally  speaking,  it 
is  quite  likely  that  the  coronary  arteries  are  more 
directly  responsible  for  the  attacks,  for  it  is  proba- 
ble that,  during  these,  ischemia  of  the  heart  muscle 


296  PAIN 

occurs,  resulting  in  a  condition  more  or  less  analo- 
gous to  intermittent  claudication.  It  seems  to  me, 
for  this  reason,  that  whenever  attacks  of  angina  pec- 
toris  are  accompanied  by  signs  of  cardiac  insuffi- 
ciency, irregular  pulse  and  general  collapse,  it  is 
logical  to  think  primarily  of  disease  of  the  coronary 
arteries. 

The  problem  is  much  more  difficult  when  with 
severe  attacks  of  pain  there  is  no  cardiac  insuffi- 
ciency. In  such  cases  the  heart  is  usually  regular, 
the  pulse  is  full  and  of  good  force,  and  it  is  likely 
that,  when  this  occurs,  the  pain  is  of  purely  aortic 
origin,  without  coronary  involvement. 

GENERAL  SYMPTOMS. — The  pains  which  accom- 
pany aortic  lesions  are,  in  a  general  way,  alike,  in 
spite  of  the  variety  of  pathological  conditions  upon 
which  they  depend. 

They  are  situated  usually  over  the  diseased 
organ,  and,  therefore,  are  felt  in  most  of  the  cases 
retrosternally.  Sometimes  there  is  only  a  feeling  of 
slight  discomfort;  in  other  cases  there  may  be  an 
extremely  painful  sensation  of  oppression. 

The  conditions  for  diagnosis  are  very  much  more 
difficult  here,  of  course,  than  in  other  organs,  because 
direct  examination  by  palpation  is  impossible.  This 
should,  however,  be  attempted  as  well  as  practicable 
by  pressure  into  the  suprasternal  fossa  and  upon  the 
abdomen. 

Acquaintance  with  the  most  common  directions 
of  radiation  is  important,  since  radiating  pains  may 
occasionally  occur  without  other  symptoms.  Eadia- 


RESPIRATION  AND  CIRCULATION       297 

tion  is  usually  along  arterial  channels,  especially 
when  the  aortic  process  is  continued,  as  in  arteritis, 
into  other  vessels  (carotid  and  subclavian).  In  such 
cases  the  vessels  involved  are  sensitive  to  pressure. 

Tugging  on  the  vessels  by  turning  the  head  or 
lifting  the  arm  is  painful,  and  subjective  pain  pos- 
sibly due  to  vascular  spasms  may  be  felt  to  extend 
even  as  far  as  the  branches  of  the  larger  trunks. 
When  the  carotid  artery  is  the  channel  of  radiation, 
symptoms  may  occur  in  the  parts  supplied  by  this 
vessel.  There  are  occasionally  unilateral  or  bilat- 
eral pains  in  the  teeth  of  the  upper  and  lower  jaws. 
Eadiation  may  occur  into  the  temporal  artery  and, 
in  addition  to  pain,  may  give  rise  to  buzzing  in  the 
ears.  When  the  subclavian  is  involved  similar 
symptoms  may  occur  in  the  upper  extremities. 

It  is  quite  reasonable,  therefore,  to  assume  that 
the  radiations  accompanying  aortic  pain  occur  along 
vascular  channels.  This,  however,  does  not  exclude 
the  possibility  that  radiations  may  occur  along  the 
brachial  plexus  and  the  intercostal  nerves  as  well. 
Frequently  the  left  brachial  plexus  is  exquisitely 
tender,  both  during  and  between  attacks.  This  may 
in  pa.rt  be  a  reflex  pain,  but  in  part  certainly  it  is 
due  to  direct  mechanical  injury  of  these  plexuses 
(large  aneurysms). 

Pains  in  the  brachial  and  cervical  plexus,  of 
course,  can  hardly  be  explained  by  direct  mechanical 
injury. 

Again,  pains  in  aortic  <lisease  can  be  explained 
on  the  basis  of  localized  nutritive  disturbances, 


298  PAIN 

brought  about  by  diminished  blood  supply.  This  is 
especially  probable  when  fever  or  metabolic  disease 
is  present.  Such  nutritive  changes  may  be  caused 
by  independent  lesions  in  the  arteries  branching 
out  from  the  diseased  aorta,  and  then  would  be 
simply  accidental  incidents  in  the  clinical  picture. 
But  they  may  also  be  more  directly  related  to  the 
aortic  lesion,  in  that  the  mouths  of  the  large  branches 
may  be  narrowed.  Such  narrowing  occurs  quite 
frequently  at  the  mouth  of  the  left  subclavian  artery 
in  cases  of  chronic  aortitis,  and  occasionally  leads 
to  complete  stenosis.  In  patients  who  are  at  the 
same  time  suffering  from  rheumatism  and  gout, 
these  localized  nutritive  changes  are  of  especial  im- 
portance. The  two  conditions  together — metabolic 
and  aortic  disease — bring  on  pains  in  the  region  of 
the  shoulder  girdle  and  in  the  thoracic  walls;  and 
while  the  pain  is  actually  caused  by  the  secondary 
condition  (gout  and  rheumatism),  it  finds  its  ulti- 
mate explanation  in  the  aortic  disease.  Such  an 
analysis  may  seem  a  trifle  overrefined,  but  it  is  ex- 
tremely important  in  the  treatment  of  the  pains. 

In  a  large  majority  of  the  cases  of  aortic  disease, 
a  definite  history  of  syphilis  can  be  elicited.  This  is 
especially  true  in  patients  who  are  still  below  middle 
life.  Whenever  apparently  rheumatic  pains  occur 
in  the  shoulder  or  along  the  upper  extremity  in  such 
individuals,  the  pains  are  probably,  as  a  whole  or  in 
part,  dependent  upon  atheroma  of  the  thoracic 
aorta;  such  suspicions  are  definitely  strengthened 
by  the  discovery  of  other  symptoms  of  aortic  disease, 


RESPIRATION  AND  CIRCULATION        299 

such  as  increase  of  arterial  tension,  aortic  pulsation 
in  the  suprasternal  fossa,  etc. 

The  radiating  pains  considered  above  are  usually 
associated  with  more  centrally  situated  pains  which 
correspond  in  their  localization  with  the  diseased 
portion  of  the  aorta.  Along  the  ascending  aorta  they 
occur  chiefly  as  deeply  situated  sensations  of  pres- 
sure along  the  lower  end  of  the  sternum.  When  the 
arch  of  the  aorta  is  diseased  the  pains  are  situated 
along  the  manubrium,  while  disease  of  the  descend- 
ing aorta  causes  pain  chiefly  in  the  back  between  the 
two  scapulas.  These  last  pains  are  situated  usually 
to  the  left  of  the  vertebral  column.  Disease  of  the 
abdominal  aorta  occasionally  gives  rise  to  pain  in 
the  left  loin  or  in  the  epigastrium. 

There  is  thus  great  variety  in  the  topographical 
characteristics  of  the  aortic  pains.  Although  in 
general  they  are  localized  in  the  thorax  they  are 
present  occasionally  in  the  neck,  head,  and  upper 
extremities,  following  in  part  the  vascular  channels 
and  in  part  the  nerve  trunks. 

The  factors  which  give  rise  to  attacks  of  aortic 
pain  are  very  few,  and  for  this  reason  they  are  of 
extreme  importance  diagnostically. 

"While  the  causes  leading  to  an  attack  may  seem 
to  be  of  many  kinds,  yet,  upon  closer  analysis,  they 
will  all  be  found  dependent  upon  a  temporary  in- 
crease of  the  strain  put  upon  the  aortic  wall  either 
by  an  absolute  or  by  a  relative  increase  of  the  intra- 
arterial  pressure.  The  causes  initiating  an  attack 
may  be  of  an  extremely  transitory  nature,  just  as  a 


300  PAIN 

single  forcible  clenching  of  the  teeth  may  give  rise 
to  a  prolonged  paroxysm  of  trigeminal  neuralgia. 
The  chief  factors  to  be  considered  are : 

1.  Increased  muscular  exertion,  such  as  rapid 
walking,  lifting  a  weight,  walking  upstairs,  rapid 
turning  in  bed,  playing  the  piano,  etc. 

2.  The  position  of  the  body.    The  horizontal  posi- 
tion, for  instance,  produces  slowing  of  the  pulse,  and 
is  usually  accompanied  by  a  greater  volume  of  car- 
diac contraction,  and  consequently  increased  pres- 
sure.    Sitting  up  in  these  cases  usually  brings  relief. 

3.  Unusual  distention  of  the  stomach  and  intes- 
tine.   Improvement  occurs  usually  after  vomiting 
and  the  expulsion  of  gas  or  feces.     Severe  attacks 
of  aortic  pain  can  unquestionably  be  caused  by 
chronic  constipation  and  meteorism,  by  excessive 
meals,  especially  when  taken  in  the  evening,  and  by 
the  ingestion  of  flatulent  food.    These  considera- 
tions are  of  extreme  importance  prophylactically 
and  therapeutically. 

The  explanation  of  this,  in  many  cases,  probably 
lies  in  the  high  position  of  the  diaphragm  accom- 
panying abdominal  distention.  In  consequence  of 
this  there  is  diminished  respiratory  suction  upon  the 
large  veins,  which  leads  to  stasis.  This,  reflexly,  by 
way  of  the  medulla,  acts  upon  arterial  conditions 
which  naturally  affect  the  aorta.  Prolonged  and 
rapid  expiration,  as  in  continued  speaking,  seems 
occasionally  to  act  in  the  same  way. 

4.  Chemical  poisons :  Alcohol,  nicotine,  lead,  gout 
and  rheumatism  are  important  etiological  factors. 


RESPIRATION  AND  CIRCULATION       301 

5.  Temperature.     The  extremes  of  temperature 
act  in  the  same  way.    Hot  rooms  or  cold  draughts, 
cold  sponging,  cold  bed,  etc.,  may  give  rise  to  aortic 
pain  or  may  occasionally  alleviate  existing  aortic 
pain;  in  some  cases  the  harmful  influence  of  cold 
weather  is  undeniable. 

6.  Psychic  influences  (excitement,  bad  dreams). 
While  these  influences  are  chiefly  important  in  their 
relation  to  the  functional  aortalgias,  they  may  never- 
theless be  of  significance  also  in  pains  of  true  aortic 
lesions.     Here,  however,  they  are  of  less  importance 
than  other  influences,  though  every  organic  disease, 
and  especially  that  connected  intimately  with  circu- 
lation, is  more  or  less  in  close  functional  relation  to 
the  nervous  system. 

7.  Pains  in  other  organs  which  lead  to  consequent 
increase  of  blood  pressure.    Such  are  cholelithiasis, 
gastric  ulcer,  etc. 

There  is  no  characteristic  time  for  the  occurrence 
of  the  attacks  of  angina  pectoris.  Whenever  the 
condition  is  based  upon  actual  organic  disease,  at- 
tacks can  often  be  produced  with  the  regularity  of 
well-planned  experiments,  if  any  one  of  the  factors 
just  mentioned  is  exerted  with  sufficient  energy. 
This  regular  dependence  upon  the  causative  factors 
is  the  chief  differential  characteristic  between  the 
functional  and  the  organic  angina  pectoris. 

In  rare  cases  attacks  may  occur  regularly  at 
night  or  during  the  early  morning  hours,  and  these 
may  be  explained  by  the  horizontal  position  of  the 
body  and  the  sudden  change  of  this  position  during 


302  PAIN 

sleep.  The  occurrence  of  distressing  dreams  may 
also  have  quite  an  important  bearing  upon  this. 

In  patients  suffering  from  metabolic  disease  the 
attacks  are  especially  frequent  at  night  and  during 
the  early  morning.  In  many  cases  they  occur  during 
the  hours  of  the  first  physical  activity  and  decrease 
during  the  course  of  the  day.  This  is  probably  due 
to  the  fact  that  occasionally  the  pathological  lesion 
in  the  aorta  is  actually  caused  by  the  metabolic  con- 
dition (gouty  arthritis). 

As  the  disease  progresses  the  free  intervals  be- 
tween attacks  seem  steadily  to  decrease  in  length. 

Chief  among  the  secondary  symptoms  found  with 
aortic  pains  is  increased  arterial  tension.  In  cases 
where  the  attacks  are  characterized  by  collapse  and 
where  they  are  dependent  more  directly  upon  coro- 
nary arteriosclerosis,  this  does  not  hold  good.  The 
pulse  and  respiration  may  be  either  increased  in 
frequency  or  slowed. 

Pulmonary  oadema  does  not  form  part  of  the 
typical  clinical  picture,  but  is  not  an  infrequent 
complication  in  cases  where  there  is  a  tendency 
toward  pulmonary  congestion. 

The  patients  themselves  during  the  attack  may 
seem  slightly  frightened,  or  they  may  go  into  col- 
lapse, with  nausea,  trembling,  and  severe  perspira- 
tion. The  characteristic  aspect  of  patients  with  the 
most  severe  attacks  is  silent  terror  and  an  expres- 
sion of  the  greatest  alarm.  Such  cases  are  often 
complicated  by  disease  of  the  coronary  arteries,  and 
are  in  marked  contrast  to  the  loud,  melodramatic 


RESPIRATION  AND  CIRCULATION       303 

behavior  of  patients  suffering  from  the  functional 
forms  of  aortic  pain. 

The  paroxysmal  attacks  of  vascular  pain  which 
we  have  just  considered  may  be  regarded  as  the  most 
severe  development  of  the  disease.  All  degrees  of 
pain,  however,  may  be  found  accompanying  the 
various  aortic  lesions.  These  are  best  considered 
in  direct  connection  with  the  various  pathological 
processes. 

ANEURYSM  OF  THE  AORTA. — The  pain  produced 
by  aneurysm  is  at  first  probably  due  to  the  stretching 
of  the  diseased  aortic  wall.  On  the  other  hand,  it 
may  also  be  due  to  the  progressive  nature  of  the 
process,  an  extension  quite  analogous  to  that  occur- 
ring with  malignant  new  growth.  The  diffuse  and 
even  distention  of  the  aorta  may  give  rise  to  pain 
independently  of  further  extension.  The  cases  of 
chief  interest  to  us  here,  however,  are  the  progres- 
sively extending  ones. 

The  mechanism  of  these  pains  is  the  same  as  that 
which  we  described  in  speaking  of  aortic  pains  in 
general ;  but  here  we  have,  in  addition  to  other  fac- 
tors, the  element  of  progressive  extension  of  the 
aneurysmal  sac  and  consequent  pressure  upon  sensi- 
tive structures.  This  source  of  pain  must  especially 
be  considered  in  cases  which  are  accompanied  by 
constant  pain,  and  a  recognition  of  this  will,  of 
course,  materially  influence  prognosis. 

Patients  suffering  from  aneurysms  occasionally 
suffer  from  a  pain  in  the  shoulder  or  in  the  upper 
extremity,  which  comes  and  goes  irregularly.  Such 


304  PAIN 

variation  makes  us  question  the  correctness  of  our 
diagnosis.  The  irregularity  can  often  be  explained, 
however,  by  temporary  exacerbations  in  the  in- 
flammatory process  of  the  aorta  and  the  perivascu- 
lar  inflammations.  These  pains  usually  correspond 
absolutely  with  the  position  of  the  aneurysmal  sac. 
Therefore  they  are  located  with  especial  frequency 
along  the  clavicle  and  are  accompanied  by  sensitive- 
ness in  the  corresponding  brachial  plexus,  the  upper 
intercostal  spaces  and  ribs.  Occasionally  pain  may 
occur  opposite  the  coracoid  process  in  Mohrenheim's 
fossa.  When  it  extends  into  the  back,  it  is  usually 
situated  over  the  left  scapula,  in  the  space  between 
the  scapula  and  the  vertebral  column,  or  just  below 
the  scapula  angle.  Occasionally  there  may  be  pain 
in  the  supraspinous  fossa. 

Retrosternal  pain  in  the  region  of  the  heart,  in 
the  shoulder  and  upper  extremity  and  in  the  inter- 
costal spaces,  however,  is  so  common  in  simple 
chronic  aortitis  that  it  is  hardly  necessary  always  to 
think  of  aneurysm  when  this  occurs.  It  is  logical 
to  think  of  aneurysm  only  when  the  symptoms  are 
constant  and  no  free  intervals  occur.  The  same  con- 
siderations apply  to  the  pains  radiating  into  the  neck 
and  occipital  region.  It  is  the  constancy  of  the  pain 
rather  than  its  localization  which  makes  the  differ- 
entiation between  chronic  aortitis  and  aneurysm. 
The  factors  modifying  the  pain  in  aortic  aneurysm 
are  the  same  as  those  mentioned  in  speaking  of 
simple  aortic  pains. 


RESPIRATION  AND  CIRCULATION       305 

Whenever  pain  in  the  shoulder  is  complained 
of,  diagnosis  should  be  made  with  extreme  care. 
Such  pains  often  occur  as  an  early  symptom  of 
aneurysm,  but  are  frequently  interpreted  as  rheu- 
matic, and  the  treatment  to  which  the  patient  is  sub- 
jected (massage,  gymnastics,  and  hot  baths)  directly 
aggravates  the  aneurysmal  dilatation.  Especial 
care  should  be  taken  to  determine  whether  the  pain 
is  increased  by  forcible  exertion,  rapid  walking,  or 
running  upstairs,  and  improved  by  rest ;  or  whether 
a  paroxysm  is  accompanied  by  cardiac  symptoms, 
such  as  palpitation,  etc.  When  the  pain  is  due  to 
aneurysm,  too,  the  motions  of  the  shoulder  joint  are 
usually  free ;  this,  however,  is  not  a  very  useful  point 
since  there  are  many  exceptions,  cases  in  which  this 
reflex  pain  in  the  shoulder  joint  leads  to  limitation 
of  movement.  Eotatory  movements  of  the  shoulder 
in  such  cases,  especially  abduction  of  the  arm  from 
the  chest  above  the  horizontal  position,  often  lead 
to  pain  in  Mohrenheim's  groove.  This  may  possibly 
be  due  to  direct  tugging  upon  the  subclavian  artery. 
Similar  tugging  upon  the  carotid  by  turning  and 
backward  bending  of  the  head  may  produce  pain  in 
the  neck  and  occiput. 

The  error  of  confusing  the  shoulder  pain  pro- 
duced by  aneurysm  with  rheumatic  pain  is  especially 
frequent  because  exposure  to  cold  and  draught  often 
produce  an  exacerbation,  and  a  local  counter-irrita- 
tion is  often  followed  by  distinct  improvement.  It 
is  not  at  all  out  of  the  question  that  in  many  of  these 
cases  there  may  actually  be  rheumatic  or  gouty  pains 
20 


306  PAIN 

in  the  joints,  since  there  is  often  such  a  diathesis 
underlying  the  vascular  disease.  The  shoulder  joint 
is  unquestionably  in  such  cases  a  point  of  least 
resistance  because  of  the  diseased  arteries  which 
supply  it. 

A  very  important  diagnostic  feature  of  the  pains 
accompanying  aortic  aneurysm  is  their  reaction  to 
changes  of  position  of  the  body. 

In  speaking  of  general  aortic  pains,  we  called 
attention  to  the  fact  that  there  is  a  marked  differ- 
ence between  the  upright  and  the  prone  positions  in 
their  influence  upon  arterial  pressure.  There  are, 
on  the  other  hand,  cases  of  aneurysm  in  which  mere 
shifting  of  position  when  the  patient  is  lying  down 
will  influence  the  pain ;  these  are  entirely  analogous 
to  similar  phenomena  occurring  in  the  abdominal 
conditions,  such  as  gastric  ulcer  and  renal  disease. 
Lying  upon  the  side  is  often  accompanied  by  great 
pain,  which  is  usually  present  when  the  patient  is 
lying  on  the  side  opposite  to  the  lesion.  This  gives 
him  the  sensation  of  something  sinking  toward  the 
healthy  side.  This  is  unquestionably  due  to  the 
change  of  position  of  the  aneurysmal  sac  and  traction 
upon  the  periarterial  adhesions.  It  is  very  impor- 
tant, therefore,  in  cases  suspicious  of  aneurysm,  to 
observe  the  influence  of  changes  of  position  upon  the 
pains. 

Theoretically  it  is  quite  obvious  that  any  agencies 
which  would  exert  traction  upon  the  sac,  such  as  deep 
breathing,  coughing  and  sneezing,  would  give  rise 
to  pain,  and  practical  experiments  bear  this  out. 


RESPIRATION  AND  CIRCULATION       307 

The  pain  may  be  especially  dependent  upon  respira- 
tion, and  it  is  of  particular  diagnostic  significance 
when  deep  breathing  gives  rise  to  extrathoracic 
pains  (for  instance,  in  the  back  of  the  neck). 

The  pain  occasionally  accompanying  the  act  of 
swallowing  is  probably  explained  by  the  motion  of 
the  larynx  during  this  act,  and  consequent  traction 
upon  the  left  bronchus  and  tugging  upon  the  aorta. 
This  pain  occasionally  radiates  into  the  shoulder 
blade  or  into  the  intraclavicular  region. 

Percussion  and  palpation  over  the  intercostal 
spaces,  the  ribs  and  the  vertebral  column  in  the 
region  of  the  aneurysm  occasionally  produce  great 
suffering. 

While  the  aneurysmal  process  is  an  entirely  con- 
stant state  of  affairs,  the  pain  need  not  be  entirely 
constant.  Variations  are  especially  frequent  in 
those  pains  which  are  based  upon  reflex  causes 
(brachial  and  cervical  plexuses,  subclavicular  and 
carotid  regions). 

Variations,  too,  in  the  pathological  conditions 
underlying  the  pains  explain  such  changes.  These 
are  chiefly  changes  in  dilatation  of  the  aneurysmal 
sac  and  fluctuations  in  the  inflammatory  process 
occurring  in  the  aorta.  These  fluctuations  may  be 
very  similar  to  those  occurring  in  rheumatic  condi- 
tions. Changes  in  the  pain  may  be  due,  on  the  other 
hand,  directly  to  variations  in  the  occasionally  com- 
plicating rheumatism. 

The  quality  of  the  pain  is  not  at  all  uniform. 
Usually  the  patients  complain  of  pulsating,  boring 


308  PAIN 

pains,  or,  again,  of  a  shooting  or  stabbing  as  with 
needles.  Almost  invariably  they  localize  their  pains 
deeply. 

We  may  frequently  be  led  in  the  right  direction 
by  considering  the  regions  secondarily  involved  in 
aneurysmal  pain,  the  shoulder  pains  being  particu- 
larly important.  In  this  connection  special  atten- 
tion must  be  paid  to  the  mechanical  influences  of 
motion  or  body  position,  which  will  help  us  tremen- 
dously even  when  other  secondary  symptoms  are 
absent. 

Other  important  symptoms  which  are  occasion- 
ally associated  are  variable  hoarseness,  which  is 
directly  dependent  in  its  intensity  upon  physical 
exertion,  difficulty  in  swallowing,  especially  the  swal- 
lowing of  cold  fluids,  and  associated  especially  with 
particular  positions  of  the  head.  There  are  often, 
too,  a  dry  hacking  cough,  which  is  influenced  defi- 
nitely by  the  position  of  the  body,  cardiac  palpita- 
tion, and  increase  of  the  shoulder  pain  following 
rapid  walking,  variations  in  the  pulse,  sometimes 
referable  to  the  sympathetic  system,  and  dilated 
veins. 

For  rapid  diagnosis  it  is  always  important  to 
examine  the  aorta  carefully  in  the  suprasternal  fossa 
and  in  the  intraclavicular  space  on  both  sides  by 
palpation  and  inspection. 

CHRONIC  AORTITIS. — In  cases  of  aneurysm  of  the 
aorta  we  had  to  deal  chiefly  with  a  constant  pain. 
In  the  cases  of  chronic  aortitis,  on  the  other  hand, 
we  deal  with  a  characteristic  paroxysmal  pain.  The 


RESPIRATION  AND  CIRCULATION       309 

chief  condition  under  consideration  here  is  that 
which  is  known  commonly  as  angina  pectoris,  and 
which  is  unquestionably  often  accompanied  by  dis- 
ease of  the  coronary  arteries.  In  order  to  avoid 
repetition  we  may  refer  to  the  section  upon  aortic 
pains  in  general.  We  have  already  called  attention 
in  that  section  to  the  secondary  pains  and  to  their 
channels  of  radiation. 

The  considerable  variations  in  the  localization 
of  the  attacks  may  be  due  to  the  varying  localization 
of  the  disease  in  the  aorta.  The  central  point  of 
these  attacks  of  pain,  that  is,  the  locality  from  which 
the  attack  emanates,  is  frequently  below  the  sternum. 
Often  the  pain  is  in  the  lower  portion  of  the  sternum 
and  extends  symmetrically  on  both  sides,  covering 
thus  an  oval  area;  more  rarely  it  extends  to  the 
suprasternal  fossa.  Occasionally,  again,  the  attack 
may  begin  with  stabbing  pains  in  the  heart  itself  or 
in  the  right  mammary  line. 

The  point  of  origin  does  not,  however,  occur 
always  in  the  thorax.  It  may  be  located  in  the  epi- 
gastrium, and  these  cases  are  the  ones  which  are  the 
most  easily  misinterpreted.  Radiation  most  fre- 
quently occurs  retrosternally  in  an  upward  direction. 

Whenever  the  epigastric  type  of  angina  pectoris 
occurs  it  is  well  to  seek  an  explanation  in  two  proba- 
bilities: (1)  involvement  of  the  abdominal  aorta,  es- 
pecially at  the  point  of  origin  of  the  eceliac  axis; 
(2)  coincident  disease  of  the  stomach  itself  (chronic 
gastritis,  ulcer,  atony,  etc.). 

The  possibility  of  sclerosis  of  the  gastric  arteries 
must  also  be  considered. 


310  PAIN 

It  is  important  to  determine  whether  or  not  the 
initial  epigastric  pain  is  truly  gastric  or  hepatic  in 
nature  (as  by  hepatic  congestion  or  cholelithiasis) 
and  whether  the  angina  pectoris  is  thereby  second- 
arily initiated. 

There  are  two  chief  types  of  radiations,  which, 
by  the  way,  may  be  entirely  absent  at  the  beginning, 
and  occur  only  later  in  the  disease. 

1.  The  symmetrical  type.    Radiations  which  are 
equally  severe  in  both  shoulders,  both  arms  (espe- 
cially the  ulnar  surfaces)  in  the  scapular  region,  both 
sides  of  the  neck,  both  sides  of  the  jaw  and  both 
temples. 

2.  The  asymmetrical  type,  which  involves  chiefly 
the  left  side  of  the  body;  radiations  occurring  into 
the  left  shoulder  and  the  left  arm,  the  back  be- 
tween the  vertebral  column,  the  left  shoulder  blade 
and  the  left  side  of  the  neck. 

While  there  are  cases  in  which  there  is  a  complete 
absence  of  radiation  there  are,  on  the  other  hand, 
cases  in  which  the  attack  begins  in  the  peripheral 
zone  and  centers  towards  the  aorta  (for  instance, 
from  one  carotid  artery  or  from  one  arm). 

These  unusual  peripheral  types  (sensations  in 
the  regions  of  the  teeth,  wrist,  olecranon,  etc.)  are 
of  the  greatest  practical  importance,  since  they  are 
so  easily  misinterpreted,  and  may  in  many  cases  be 
the  forebodings  of  sudden  death. 

In  the  histories  of  the  patients  with  chronic 
aortitis  and  coronary  sclerosis  we  may  often  trace 
the  earliest  beginnings  of  the  fully  developed  attacks 


RESPIRATION  AND  CIRCULATION       311 

to  stages  where  there  were  centrally  localized  pains 
only.  These  early  stages  consist  usually  in  slight, 
hardly  noticeable,  sensations  of  pressure  behind  the 
lower  part  of  the  sternum,  or  occasional  mild,  stab- 
bing pains  in  the  heart  produced  by  rapid  motion, 
occurring  especially  in  the  morning.  From  these 
very  slight  beginnings  gradually  the  terrible  picture 
of  a  severe  angina  develops.  The  intervals  between 
the  attacks  become  shorter  and  shorter,  and  the 
stimulus  necessary  for  their  occurrence  becomes 
slighter. 

As  far  as  the  causes  giving  rise  to  attacks  are 
concerned  we  may  refer  to  the  section  upon  aortic 
pain  in  general. 

The  basis  for  these  causal  factors  consists  in  the 
increased  blood  pressure  and  secondary  distention 
of  the  diseased  aortic  walls,  and  upon  the  nerve  end- 
ings embedded  in  them.  The  more  frequently  the 
attacks  occur,  the  more  slight  the  stimuli  necessary 
for  attacks  become,  the  more  serious  is  the  prog- 
nosis. The  prognosis  is  especially  bad  in  cases 
where  the  attacks  are  accompanied  by  great  nausea. 
The  secondary  symptoms  which  are  most  important 
in  rapid  diagnosis  are  an  accentuated  ringing  second 
aortic  sound,  increased  tension  in  the  arteries,  and 
angiosclerotic  pallor  of  the  face. 

DISEASE  OP  THE  AORTIC  VALVES  (ENDOCARDITIS) 
WITHOUT  DISEASE  OF  THE  AORTIC  WALL. — There  are 
unquestionably  cases  of  aortic  pain  corresponding 
in  their  localization  and  general  behavior  with  the 
pains  which  we  have  described,  without  the  presence 


312  PAIN 

of  any  traceable  disease  of  the  aorta  itself  or  the 
coronary  arteries.  In  some  of  these  cases  there 
may  be  simply  diseases  of  the  aortic  valves,  in  others 
even  these  may  be  absent.  Such  cases  give  striking 
proof  of  the  nervous  origin  of  angina  pectoris  and 
aortic  pain  in  general.  The  origin  of  the  pain  in 
such  cases  is  unquestionably  in  the  cardiac  and 
aortic  plexuses  of  the  sympathetic  system.  In  or- 
ganic disease  of  the  aorta  these  may  be  the  sites  of 
actual  neuritis  and,  therefore,  react  acutely  to  in- 
jury, to  disturbances  of  the  circulation  in  the  vasa 
vasorum,  or  especially  to  distention  of  the  aortic 
walls.  They  may,  on  the  other  hand,  without  trace- 
able anatomical  reason,  be  the  seats  of  neuritis, 
especially  in  persons  who  are  subject  to  general 
irritability  of  the  nervous  system.  Such  attacks  of 
pain  may  be  known  as  functional  angina  or  false 
angina ;  but  we  must  clearly  understand  that  while 
the  special  pathological  changes  in  these  conditions 
are  very  different,  the  general  origin  of  the  pains 
may  be  much  the  same. 

The  stimulus  initiating  such  attacks  of  functional 
aortic  pain,  therefore,  may  often  be  increase  of  blood 
pressure,  due  to  spasms  in  the  peripheral  vessels. 
It  is  certainly  not  a  chance  occurrence  that  func- 
tional angina  is  found  most  frequently  in  young 
neurasthenic  individuals  with  disease  of  the  aortic 
valves.  The  neurotic  disposition  prepares  the  field 
and  the  pathological  pressure  in  the  aorta  gives 
the  actual  stimulus. 


\ 
RESPIRATION  AND  CIRCULATION    \313 

The  differentiation  between  functional  and  6r- 
ganic  angina  pectoris  is  of  extreme  prognostic  ini- 
portance  and  is  recognized  by  the  analysis  of  the 
factors  initiating  an  attack  and  of  the  secondary 
symptoms.  As  far  as  the  initiating  stimuli  are  con- 
cerned, however,  it  is  quite  important  to  remember 
that  both  the  conditions  have  many  of  these  in 
common. 

As  for  angina  pectoris  which  is  based  upon  actual 
organic  disease,  we  may  say  that  we  are  dealing  with 
an  exact  problem.  The  patient  himself  knows  that 
if  he  runs  a  certain  distance  at  a  definite  speed  he 
will  have  an  attack.  He  can  make  a  definite  calcu- 
lation, as  it  were,  of  the  factors  which  will  give  rise 
to  the  attack. 

The  functional  angina,  on  the  other  hand,  is  en- 
tirely beyond  control,  is  irregular,  and  is  uncertain. 
In  all  respects  functional  angina  pectoris  is  a  sort 
of  farcical  parody  of  the  tragic  true  angina.  Even 
the  most  severe  cases  lack  the  serious  character  of 
the  true  organic  angina.  The  blood  pressure  is  not 
usually  increased;  the  face  is  often  flushed  instead 
of  pale.  Instead  of  seriousness  and  quiet,  there  is 
restlessness  and  noise.  The  heart  action  is  usually 
rapid. 

The  extremes  of  the  two  cases,  therefore,  are  not 
hard  to  differentiate;  but  unfortunately  a  mixture 
of  the  two  conditions  is  very  common.  There  are 
cases  in  which  a  general  neurosis  becomes  localized 
in  the  diseased  aorta  and  adds  the  characters  of  a 
well-developed  functional  condition  to  the  early 


314  PAIN 

symptoms  of  a  true  angina.  Such  cases  are  often 
f jlsely  diagnosed  and  are  taken  for  pseudo-angina 
until  sudden  death  occurs.  No  general  differential 
symptoms  can  be  formulated  for  these.  Only  the 
most  careful  individual  study  of  the  symptoms  and 
the  most  concentrated  analysis  of  the  problem  can 
guard  us  against  error. 

Functional  angina  is  especially  likely  when  we 
are  dealing  with  neurasthenic  patients  below  thirty, 
when  syphilis  can  be  excluded,  and  especially  when 
there  is  excessive  use  of  tobacco.  This  is  likely  even 
when  an  aortic  valvular  lesion  is  present.  Above 
thirty,  and  especially  above  forty,  the  differential 
diagnosis  becomes  particularly  difficult. 

True  angina  must  always  be  considered  most 
seriously,  even  in  the  presence  of  neurotic  symp- 
toms, when  there  is  arterial  tension,  a  history  of 
syphilis,  or  when  gout  or  rheumatism  is  present. 

PERIPHERAL  VESSELS. 

It  is  well  known  and  based  on  many  clinical  ob- 
servations that  severe  pains  may  be  caused  by  disease 
of  the  peripheral  arteries,  veins,  or  lymph  vessels. 
It  would  be  quite  incomprehensible  if  this  were  not 
the  case,  since  the  nerve  trunks  themselves  possess 
their  own  vessels,  and  it  goes  without  saying  that 
when  these  are  diseased,  either  primarily  or  second- 
arily, errors  of  nutrition  must  occur  in  the  nerves, 
and  these  therefore  become  the  seats  of  pain. 

In  this  connection  the  very  intimate  relations 
between  the  vessels  and  the  nerves  must  be  carefully 


\ 

RESPIRATION  AND  CIRCULATION        315 

considered.  On  the  other  hand,  changes  in  the  ves- 
sels and  circulation  may  cause  disease  in  the  nerves, 
while  disease  in  the  nerves  may  cause  disease  in  the 
vessels.  The  pathogenesis  of  the  pains,  therefore, 
is  extremely  difficult  to  determine. 

Clinical  experiment  alone  can  lead  us  to  the  cor- 
rect interpretation.  It  is  a  fact  that  subjective  and 
objective  pains  occur  along  the  peripheral  vessels 
when  they  are  involved  in  inflammations  (phlebitis, 
lymphangitis,  arteritis),  and  there  is  no  reason  for 
not  interpreting  such  pains  as  irritability  of  the 
sensory  fibers  supplying  the  vessel  walls.  In  some 
cases,  of  course,  it  is  necessary  to  think  of  a  direct 
extension  of  the  inflammatory  process  from  the  ves- 
sels to  the  nerves  which  accompany  them.  Many 
cases  of  neuralgia  are  probably  traceable  to  such 
changes  in  the  vessels  accompanying  the  involved 
nerves. 

It  is  unquestionable  that  sclerotic  changes  in  the 
peripheral  arteries,  both  in  the  extremities  and  in 
the  internal  organs,  may  give  rise  to  acute  neuralgic 
attacks  of  pain.  The  most  striking  and  fundamen- 
tal example  of  this  is  Charcot's  intermittent  claudi- 
cation,  since  this  can  be  directly  observed. 

After  a  few  minutes  of  walking  the  patient  has 
pains  in  his  calves  which  force  him  to  stand  still. 
The  pain  then  disappears ;  the  patient  continues  his 
walk,  but  in  a  few  moments  the  same  symptoms 
occur;  and  with  the  absolute  regularity  of  a  well- 
planned  experiment  the  same  symptoms  follow  the 
same  exertion  again  and  again. 


316  PAIN 

Physical  examination  in  these  cases  shows  scle- 
rotic changes  in  the  vessels,  either  local  with  the 
formation  of  aneurysm,  or  diffuse  changes  in  the 
iliac  arteries  extending  downward  with  or  without 
stenosis,  or  more  or  less  severe  vasomotor  phe- 
nomena (coldness,  pallor,  redness  and  cyanosis  of 
the  toes) ;  death  finally  occurs  with  gangrene  of  the 
toes. 

The  mechanism  of  the  pain  in  these  cases  is  not 
easy  to  explain.  Are  we  dealing  with  chronic  nutri- 
tional disturbances  in  the  sensory  nerves  which 
reach  their  greatest  height  during  the  circulatory 
changes  accompanying  muscular  action,  or  are  we 
dealing  with  acute  ischemia  of  the  active  masses  of 
muscle  due  to  arterial  spasms  1 

The  mechanism  of  the  pain  is  not  necessarily 
uniform.  But,  at  any  rate,  it  is  certain  that  the 
clinical  observations  cannot  be  explained  without  the 
assumption  of  vascular  spasms,  to  which  sclerotic 
vessels  are  always  subject.  Otherwise  the  constancy 
of  the  anatomical  changes  would  have  to  be  fol- 
lowed by  a  constancy  of  the  clinical  symptoms,  while 
as  a  matter  of  fact  clinical  experiment  teaches  us 
that  proper  treatment  may  often  give  the  most 
remarkable  results  in  a  short  time.  Improvement 
may  even  occur  spontaneously. 

This  unquestionably  functional  factor  in  the 
causation  of  intermittent  claudication  makes  it 
almost  impossible  to  deduct  the  cause  of  a  given 
pain  from  definite  anatomical  conditions  of  the  arter- 
ies. Unquestionably  severe  atheroma  may  be  pres- 


RESPIRATION  AND  CIRCULATION       317 

ent  in  the  vessels  of  the  leg  without  the  existence 
of  any  pain.  For  this  reason,  even  in  cases  where 
angina  pectoris  has  been  observed  during  life,  it  is 
not  always  a  foregone  conclusion  that  the  finding 
of  c6ronary  sclerosis  at  autopsy  absolutely  explains 
the  symptoms. 

The  pains  occurring  in  intermittent  claudication, 
too,  find  their  analogy  in  diseases  of  the  viscera. 

It  may  be  considered  an  established  fact  that 
diseases  of  cardiac,  gastric,  or  intestinal  arteries 
may  give  rise  to  painful  interferences  with  function. 

In  order  to  draw  an  intelligent  parallel,  however, 
between  the  intermittent  claudication  of  the  lower 
extremities  and  the  pathological  conditions  of  inter- 
nal organs,  we  must  consider  only  those  cases  in 
which  there  is  real  similarity  between  the  existing 
stimulus  and  the  therapeutic  influences.  The  at- 
tacks of  pain  must  occur  at  the  height  of  the  mus- 
cular exertion,  that  is,  at  the  height  of  digestion, 
as  in  arteriosclerotie  intestinal  pains,  and  be  accom- 
panied by  disturbance  of  motility  in  the  sense  of 
spasm  and  loss  of  function. 

In  the  heart  this  might  become  evident  by  cardiac 
insufficiency  with  arhythmic  feeble  pulse.  In  the  in- 
testine it  might  be  noticed  as  a  stenosis  or  distention 
which  could  simulate  peritonitis ;  and  this,  as  a  mat- 
ter of  fact,  actually  occurs  in  a  number  of  cases. 

It  is  true,  too,  that  cases  of  this  order  can  be 
therapeutically  influenced  (erythrol  tetranitrate) . 

Probably  in  all  these  conditions  the  organic  basis 
of  the  pains  consists  in  an  active  intermittent  spasm 
of  the  vessels. 


318  PAIN 

Either  in  the  last  stages  of  these  conditions  or 
even  as  an  entirely  independent  condition,  pains  may 
occur  in  which  the  vessels  play  a  more  passive  role. 
Closure  of  the  vessels  by  thrombosis  or  embolus 
may  give  rise  to  pain  in  consequence  of  anaemic 
necrosis  of  the  sensory  nerve  endings  and  their 
dependent  tissue  regions. 

The  severe  pain  occurring  in  gangrene  of  the 
toes  and  the  sudden  pains  which  occur  in  the  lower 
extremities,  with  embolus  or  thrombosis  of  the  lower 
portion  of  the  abdominal  aorta,  would  belong  to  this 
order. 

The  accompanying  symptoms,  coldness  of  the 
affected  area  and  a  loss  of  the  motor  and  sensory 
functions,  will  usually  clear  up  the  diagnosis. 

Similar  processes  in  the  chest,  abdomen  and  vis- 
cera will,  of  course,  give  rise  to  great  diagnostic 
difficulties. 

Stenoses  of  the  mesenteric  arteries  frequently 
lead  to  the  erroneous  diagnosis  of  intestinal  obstruc- 
tion and  peritonitis.  "Whenever  sudden  colicky 
pains,  either  with  or  without  bloody  diarrhoea,  occur 
in  patients  with  noticeable  arterial  disease,  it  is 
always  important  to  think  of  the  possibility  of  dis- 
ease of  the  mesenteric  vessels. 

Closure  of  the  veins  as  well  as  of  the  arteries  may 
give  rise  to  severe  pains.  A  notable  example  of 
this  is  the  headache  accompanying  thrombosis  of 
the  lateral  sinus,  and  the  phlegmasia  alba  dolens 
following  closure  of  the  large  veins  of  the  leg. 


CHAPTER  X. 

CUTANEOUS  TENDERNESS  IN  VISCERAL  DISEASE. 

WHILE  the  fact  that  diseases  of  the  internal 
organs  may  be  accompanied  by  areas  of  cutaneous 
tenderness  or  pain  more  or  less  remote  from  the 
actual  seat  of  disturbance  had  previously  been  com- 
mented on  by  various  observers,  notably  Hilton, 
Dana,  Boss,  and  Mackenzie,  it  is  largely  through  the 
brilliant  researches  of  Henry  Head  that  the  real 
significance  of  this  phenomenon  has  been  made  clear. 
His  explanation  for  this  transference  of  sensation 
is  that  a  painful  stimulus  to  an  internal  organ  causes 
centripetal  impulses,  ordinarily  below  the  threshold 
of  consciousness,  to  be  conducted  to  a  certain  seg- 
ment of  the  spinal  cord.  Here  a  more  or  less  diffuse 
disturbance  is  induced  which  involves  also  the  fibres 
connecting  a  definite  district  of  the  surface  of  the 
body  with  the  same  segment.  As  the  function  of 
sensation  has  been  very  highly  developed  in  the  skin 
its  sensory  and  localizing  power  is  enormously  in 
excess  of  that  of  the  viscera,  so  that  the  painful 
sensation  is  referred  in  consciousness  not  to  its  true 
source,  but  to  the  site  from  which  such  messages 
are  habitually  received, — i.e.,  the  surface  of  the  body. 
According  to  the  intensity  of  the  visceral  stimulus, 
actual  pain  may  be  experienced,  or  there  may  result 
only  a  state  of  hyperaesthesia  or  hyperalgesia  which 

319 


320  PAIN 

manifests  itself  by  an  increased  susceptibility  to 
stimuli,  so  that  contacts  which  would  ordinarily  evoke 
only  sensations  of  touch  now  give  rise  to  actual  pain. 
In  order  to  discover  the  presence  of  such  areas  of 
tenderness  and  ascertain  their  boundaries,  the  exam- 
iner may  use  a  pin  with  a  round  head  of  such  size 
as  to  feel  blunt  when  applied  to  normal  skin.  Pres- 
sure is  made  with  this  here  and  there  over  the  sus- 
pected region,  and  if  hyperalgesia  exists  the  patient 
complains  of  a  sensation  as  if  a  bruised  spot  were 
touched,  while  if  the  point  of  the  instrument  is 
applied  the  pain  is  far  in  excess  of  that  normally 
produced. 

Head  was  led  to  investigate  the  subject  by  the 
observation  that  the  distribution  of  the  lesions  in 
cases  of  herpes  zoster  corresponded  with  the  areas 
of  cutaneous  pain  or  tenderness  occurring  in  certain 
visceral  disorders,  and  by  comparing  the  areas  in- 
volved in  a  large  number  of  cases  of  herpes  zoster 
with  the  disturbances  of  sensation  in  a  series  of 
cases  of  nervous  disease  with  gross  lesions  of  the 
spinal  cord,  he  was  able  to  map  out  on  the  surface 
of  the  body  the  skin  units  or  dermatomes  in  com- 
munication with  the  various  segments  of  the  cord. 
These  areas  correspond,  not  to  the  peripheral  distri- 
bution of  the  posterior  roots,  but  to  the  segments  of 
the  cord  itself  from  which  the  roots  in  part  arise. 
The  skin  areas  as  traced  by  Head  on  the  trunk 
form  more  or  less  horizontal  zones  of  irregular  out- 
line, while  about  the  neck  and  on  the  limbs  their 
eccentricity  of  contour  is  still  more  pronounced.  The 


VISCERAL   DISEASE  321 

whole  area  is  not  necessarily  involved  in  every  case, 
but  each  segments!  district  possesses  one  or  more 
maximal  points  in  which  the  tendency  to  exhibit  pain 
or  tenderness  is  most  acute  and  which  give  the  clue 
to  the  area  concerned. 

Subsequent  observers  have  Verified  Head  '«*»  con- 
clusions in  most  particulars,  and  while  f'ne  limits 
of  the  various  areas  as  given  by  differ?*^  authors  do 
not  in  all  cases  coincide  absolutely,  ^  is  probable  that 
the  maximal  points  on  Head's  digrams  are  correct. 
For  practical  purposes,  at  anv  rate,  the  chief  interest 
attaches  to  these,  so  that  fr>^  this  reason,  and  for  the 
sake  of  greater  clearness,  on  the  following  figures 
/only  the  so-called  m?  *ima  are  indicated.  It  must  be 
remembered,  however,  that  for  the  present  at  least, 
the  evidence  sdt-ord&l  by  the  demonstration  of  areas 
of  cutaneouat  tenderness  or  pain  is  valuable  chiefly 
in  the  positive  sense  and  that  their  absence  does  not 
preclude  tlr-  existence  of  visceral  disease.  Further- 
more, in  /Any  given  cases  these  areas  do  not  neces- 
sarily preserve  their  integrity  indefinitely,  but  as 
the  nenp^HS  system  becomes  impaired  as  the  result 
of  prolonged  illness,  first,  the  corresponding  dis- 
trict (  'he  opposite  side  of  the  body  may  become 
'm,  ul  later  on  still  more  marked  generaliza- 

tion i      y  occur  until  the  pain  and  tenderness  invade 
iiat  bear  no  relation  to  the  affected  organ, 
pc  nt  of  practical  importance  is  that  counter- 
jr:ritntion  over  the  cutaneous  area  may  have  thera- 
Hpeutic  value,  not  only  in  the  immediate  relief  of 
Bpain,  but  also  in  influencing  the  underlying  condition. 


322  PAIN 

SEGMENTAL  DISTRIBUTION   OF   REFERRED   PAIN   AND 
TENDERNESS  IN  VISCERAL  DISEASE. 

(Compiled  from  Head.) 
See  diagrams  figures  1,  2,  and  3. 
.—Third  cervical  and  first,  second,  and  third  dorsal  seg- 

.._Third  and  fourth  cervical  and  first  to  ninth  [sometimes 

•-al  seenient*,  especiallv  the  third,  fourth,  and  fifth. 
Breatr 

"-urth  and  fifth  dorsal  segments. 
(Esophagr* 

™fth,  sixth,  and  eighth  dorsal  segments. 
Stomach. — Th,.   '  ,,       .  JL, 

-d  fourth  cervical  and  sixth,  seventh,  eighth, 
and  ninth  dorsal  segn,  .   , .        ,  .-. 

Cardiac  end  from  the  sixth  and  seventh, 
and  the  pyloric  end  froi; 

r  ninth. 
Intestines. — Down  to  the  ,T.    ,,  .-. 

-*er  part  of  the  rectum:  Ninth,  tenth, 

eleventh,  and  twelfth  dorsal  st,.  ,    ,,.   -,         * 

'  <ts.     Rectum:   Second,  third,  and 
fourth  sacral  segments. 

Liver  and  Gall-bladder. — Seventh,'*:  ,,    j^_aQf 

*h,  ninth,  and  tenth  dorsal 

segments,  and  perhaps  the  sixth. 

Kidney   and   Ureter. — Tenth,    eleventh,    a.     i    .,  ,     ,        •>         _ 
ments.     The  nearer  the  lesion  lies  to  the  kia      ,,  •     x^ 

pain  and  tenderness  associated  with  the  tenth  i.  rm,- 

lal  segment.     Ine 

lower  the  lesion  in  the  ureter  the  more  does  the  fi*'.«^  i       segment 
tend  to  appear. 

Bladder. — Mucous  membrane  and  neck  of  the  bla<?  .   -p'r^i,    «ec- 

ond,  third,  and  fourth  sacral  segments.     Overdistenti  ^   ^pffpc- 

tual    contraction:    Eleventh    and    twelfth    dorsal    ana»     ,    i,.  ,,v.nr 

nrs  L    i  it  ill  u*i  r 
segments. 

Prostate. — Tenth,  eleventh,  and  twelfth  dorsal,  first,     ond    an(j 
third  sacral,  and  third  lumbar  segments. 

Epididymis. — Eleventh  and  twelfth  dorsal  and  first        , 
ments. 

Testis. — Tenth  dorsal  segment. 

Ovary. — Tenth  dorsal  segment. 

Uterine  Appendages. — Eleventh  and  twelfth  dorsal  and  first, 
bar  segments. 

Uterus. — In  contraction:  Tenth,  eleventh,  and  twelfth  dorsal  ai, 
first  lumbar   segments.     Os  uteri:    First,   second,   third,   and   fourth 
sacral  segments,  and  very  rarely  the  fifth  lumbar. 


VISCERAL  DISE 


323 


PAINFUL  AREAS  ABOUT  THE  HEAD  RELATED 
TO  VISCERAL  DISEASE. 

(Head.) 
See  diagram  figure  4. 


S  Area  on  Body. 

Associated  Area  on 
Head. 

Organs  in  Particular  Relation  with 
these  Areas. 

Bervical  3  and  4 

worsal  2  and  3  . 
Btorsal  4  

Fronto-nasal  

Mid-orbital  
Doubtful  

Apices    of   lungs,    stomach,   liver, 
aortic  orifice  (?) 
Lung,  heart,  arch  of  the  aorta. 
Lung. 

Jporsal  5  

Fron  to-  temporal  . 

Lung  and  occasionally  the  heart. 

4)orsal  6  

Fronto-  temporal. 

Lower  lobe  of  lung,  and  heart. 

Dorsal  7  . 

Temporal  

Bases  of  lungs,  heart,  and  stomach 

Dorsal  8  

-Vertical  

Stomach,  liver,  and  upper  part  of 

Dorsal  9 

Parietal  

the  small  intestine. 
Stomach,  and   upper  part  of   the 

t 

Dorsal  10 

Occipital  

small  intestine. 
Liver,  intestine,  ovary,  and  testicle. 

324 


AIN 


AREAS  OF  REFERRED  PAIN  AND  TEwSX??8  IN  AFFEC' 
TIONS  OF  THE  HEAD  AND  NEC 

(Head.) 
See  diagram  figure  4. 


Organ  Involved. 

Maximum  Point 
of  Referred  Pain  and 
Tenderness. 

Organ  Involved. 

Maximum  P«  n(1 
of  Referred  T'aiii 
TendernesSBB 

Ciliary  muscle. 
(Disorders  of 
accommoda- 
tion.) 
Cornea  

Midorbital. 

Frontonasal. 

Frontotemporal  , 
temporal,  and 
maxillary. 
Temporal. 

Vertical. 
Hyoid. 

Vertical  and  be- 
hind the  ear. 

Upper  teeth  .  .  . 

Lower  teeth.  .  . 

Tongue,   ante- 
rior part. 

Tongue,  lateral 
part. 

Tongue,  poste- 
rior part. 

Tonsil  

Frontonasal,  naso- 
labial,  temponi 
maxillary,  or 
mandibular. 
Mental,  hyoid,  8Kb 
perior  laryngeklj 
and  in  the  ear.  "X 
Mental. 

Hyoid,    superio^ 
laryngeal,  and  in 
the  ear. 
Superior  laryngeal, 
hyoid,  occipital. 
Hyoid  and  in  the 
ear. 
Frontonasal    and 
midorbital. 
Nasolabial     (occa- 
^ionally)  . 

Superior    and    in- 
ferior  laryngeal 
(in  destructive 
lesions)  . 
^ 

Iris  

Vitreous    body 
(Glaucoma.) 

Retina  

Tympanic  mem- 
brane. 
Middle  ear  .... 

Nose,  olfactory 
portion. 
Nose,    respira- 
tory portion 
and  poste- 
rior nares. 
Larynx  

D  11 


FIGURE  1. — C  S  and  C  4  .third  and  fourth  cervical;  D  1  to  D  IS,  first  to 
twelfth  dorsal ;  L  /  and  L  2,  first  and  second  lumbar ;  5  3  and  S  4,  third  and 
fourth  sacral. 


C  3 


D  11 


S  2 


D  10 


D  12 


S  1 


FIGURE  2. — C,  cervical ;  D,  dorsal  /  L,  lumbar ;  S,  sacral. 


D  2 


L  1 


L  5 


FIGURE  3. — D,  dorsal ;   L,  lumbar. 


Neuritis  of  Bra- 
chial  Plexus. 


Neuritis. 

Neuralgia. 

Progressive  Muscu- 
lar Atrophy 

Syringomyelia. 

Disease    of    Verte- 

'    brae. 

Occupation  Neu- 
roses. 


Tabes. 


steomalacia. 


Disease  or  Injury 
of  the  Cord  (es- 
pecially Tabes). 


FIGURE  5. — POSSIBLE  AREAS  OF  PAIN  OH  TENDERNESS  IN  DISEASES  OF  THE  NERVOUS 

SYSTEM,  ETC. 


Neurasthenia. 

Meningitis. 

Cerebellar  Disease. 

Sub-occipital  Neu- 
ralgia. 

Disease  of  Cervical 
Vertebra. 

Affections  of  Naso- 
Pharynx.  Nose, 
and  Middle  Ear. 

Uremia. 

Syphilis. 


Osteomalacla 


Hypertension 

Headache. 

Neurasthenia. 


Neuritis    of    Bra- 
chial  Plexus. 


Neurasthenia. 

Railway  Spine. 

Meningitis. 

Myeli  ti  s  or  Tu- 
mors of  Cord. 

Disease  of  Vert  e- 
brae. 

Typhoid  Spine. 

Spondylitis  Defor- 
mans. 

Lumbo-abdominal 
Neuralgia. 

Lumbago. 


FIGURE  6. — POSSIBLE  AREAS  OF  PAIN  OR  TENDERNESS  IN  DISEASES  or  THE  NERVOUS 

SYSTEM,  ETC. 


Hepatic  Conges- 
tion. 

Gallstone  Disease. 

Intestinal  Ulcera- 
tion. 

Ulcer  of  Stomach. 

Lead  colic. 

Pancreatic  Dis- 
ease. 

Appendicitis. 

Renal   Affections 


Ulcer  of  Stomach. 

Gallstone  Disease. 

Intestinal  Ulcera- 
tion. 

Pancreatic  Disease. 

Appendicitis. 

Hernia. 

Affections  of  Rec- 
tum. 

Vertebral  Disease. 


Constipation. 
Gastric  Disorders. 


Constipation. 

Colitis. 

Gastric  Disorders. 


Gastralgia  and 
Functional  Disor- 
ders of  Stomach. 

Gastric  Distention. 

Ulcer  of  Stomach 
or  Duodenum. 

Carcinoma  of  Sto- 
mach. 

Ulcer,  New  Growth 
or  Stricture  of 
Esophagus. 


Punctional  Disor- 
ders of  Stomach. 

Gastritis. 

Ulcer  and  Carcino- 
ma of  Stomach. 

Pyloric  Colic. 

Enteroptosis. 

Splenic    Disease. 

Movable   Kidney. 

Renal  Colic. 


Ulcer  of  Stomach. 


Colitis. 

Testicular  or  Ovarian  Affections. 

Renal  Colic. 

Hernia. 

Constipation. 

FIGURE  7. — POSSIBLE  AREAS  OF  PAIN  OR  TENDERNESS  IN  DISEASES  OF  THE  ABDOMINAL 

ORGANS. 


Pregnancy. 
Uterine  or  Ova- 
rian Disease. 


Head's  Triangle  in 
Ulcer  of  Stomach. 


Gallstone  Disease 
and  Affections  of 
Gall-bladder. 


Pancreatic  Disease 

Appendicitis. 
Ureteritis. 


Gastralgia. 

Ulcer  of  Stomach. 

Carcinoma  of  Sto- 
mach. 

Flatulence. 

Enteroptosis. 

Dietl's  Crises. 

Lead  Colic. 

Peritonitis. 

Tuberculous  Peri- 
tonitis. 

Intestinal  Obstruc- 
tion. 

Intestinal  Ulcera- 
tion. 

Enteritis. 

Hernia. 

Pancreatic  Disease. 

Tabes. 

Spinal  Disease. 

Gout. 


Ovaritis. 


Cystitis. 
Tuberculosis  or 
Carcinoma  of  Bladder. 
Vesical  Calculus. 
Prostatic  or  Adnexal  Disease. 

FIGURE  8. — POSSIBLE  AREAS  OF  PAIN  OR  TENDERNESS  IN  DISEASES  OF  THE  ABDOMINAL 

ORGANS,  ETC. 


Splenic  Affections. 

Gastric  Disorders. 
Constipation. 

reinoma  of  Colon   or 

Pancreas. 
Movable  Kidney. 
Pyelitis. 
Subphrenic  Abscess. 


Renal  Colic. 


FIGURE  9. — POSSIBLE  AKEAS  OF  PAIN  OR  TENDERNESS  IN  DISEASES  OF  THE 
ABDOMINAL  ORGANS. 


Gallstone  Disease  and  Af- 
fections of  Gall-bladder. 

Hepatic  Disease:  Cir- 
rhosis.Cqngestion,  Syph- 
ilis, Carcinoma,  Abscess, 
Echinococcus  etc. 

Subphrenic  Abscess. 

Carcinoma  of  Pylorus  or 
Colon. 

Movable  Kidney. 

Pyelitis. 


FIGURE  10. — POSSIBLE  AREAS  OF  PAIN  OK  TENDERNESS  IN  DISEASES  or  THE 
ABDOMINAL  ORGANS. 


Gastric  Affections. 
Constipation. 


Ulcer  of  the  Sto- 
mach. 


Spleen. 
Pancreas. 


Lumbago. 

Flatulence. , 

Constipation. 

Renal  Calculus  or 
New  Growth. 

Movable   Kidney. 

Pyelitis. 

Acute  Nephritis. 

Lumbar  Abscess. 

Vesical  Calculus. 

Cystitis. 

Prostatic  New 
Growth  or  Sup- 
puration. 

Ischiorectal  Ab- 
scess. 

Fever,  (Acute  In- 
fectious Dis- 
eases etc.) . 

Anemia. 

Gout. 


Coccygodynia. 
Anal  Fissure. 
Hemorrhoids. 
Rectal  Fistula. 
Ischiorectal  Abscess. 

FIGURE  11. POSSIBLE  AREAS  OF  PAIN  OB  TENDERNESS  IN  DISEASES  OF  THE  ABDOMINAI 

ORGANS,  ETC. 


Esophagus:  In- 
fl  animation, 

Stricture,  New 
"rowths,  Ulcer- 
atiqn,  etc. 

Gastric  Affections. 

Flatulence. 

Pancreatic  Disease. 


Liver   and    G  a  1 1- 
bladder. 


Ion. 


.Kidney. 

Renal    Affections. 

Relaxation  of 
Sacro-iliac  Lig- 
aments. 

Disease  of  Pelvic 
Viscera. 

Rectal  Carcinoma 
or  Ulceration. 

Hemorrhoids. 

Ischiorectal   A  b  - 
scess. 


Diaphragmatic 
Pleurisy. 


Mediastinal 
Growths. 

Enlarged    Bron- 
chial Glands. 

Bronchitis. 

Miliary     Tubercu- 
losis. 


Pneumonia. 
Empyema. 


Pneumonia. 
Pleurisy. 


Pleurisy. 
Apical  Lesions. 
New  Growths. 


leurisy. 

New  Growths  of 
Lung  or  Pleura. 

Diaphragmatic 

Pleurisy. 
Pneumonia. 


eurisy. 

•Prolonged    C^ugh- 
ing  or  Vomiting. 

Pneumonia. 
Pleurisy. 
Diaphragmatic 
Pleurisy. 


FIGUHE   12. — POSSIBLE  AREAS  OF  PAIN  OK  TENDERNESS  IN  DISEASES  OF  THE  LUNGS  AND 

PLEURA. 


Pleural  Affections. 

Muscular  Pain  after  Pro- 
longed Coughing  or 
Vomiting. 


Pneumonia. 

Tuberculosis. 

Empyema. 

Pleurisy. 

New  Growths  of  Pleura  or 

Mediastinum. 
Enlarged    Bronchial 

Glands. 
Pleurodynia. 


FIGURE  13. — POSSIBLE  AREAS  OP  PAIN  OR  TENDERNESS  IN  DISEASES  OF  THE  LUNGS 

AND  PLEURA. 


Diaphragmatic 
Pleurisy. 


Tuberculosis. 
Pleural  Adhesions. 
Glandular  Enlarge- 
ments. 


Pleurisy. 
New  Growths. 
Apical  Lesions. 


Mediastinal 
Growths. 


FIGURE  14. — POSSIBLE  AREAS  OF  PAIN  OR  TENDERNESS  IN  DISEASES  OF  THE  LUNGS  AND 

PLEURA. 


Atheroma  of  Aorta 
and  Large  Ves- 
sels. 

Aneurysm  of  In- 
nominate. 


Arch  of  Aorta. 


Ascending  Aorta. 


Valvular  Lesions. 

Pericarditis. 

Angina  Pectoris. 

Aneurysm  of  Ab- 
dominal Aorta  or 
Coeliac  Axis. 

Spasm  of  Mesen- 
teric  Vessels. 


A  neurysm   of 
•Aorta. 


Atheroma    of 

Aorta. 
Aneurysm   ot 

Aorta. 

Angina  Pectoris. 
Coronary  Sclerosis. 
Valvular  Lesions. 


Atheroma    of 
Aorta. 

Aneurysm    of 
Aorta. 

Coronary  Sclerosis. 

Angina  Pectoris. 

Pericarditis. 

Myocarditis. 

Endocarditis. 

Valvular    Lesions 
(especially  Aor- 
tic). 

Functional  Dis- 
ease of  the 
Heart. 

Anemia. 

Gout. 


FIGURE  15.- 


-POSSIBLE  AREAS  OF  PAIN  OR  TENDERNESS  IN  DISEASES  OF  THE  HEART  AND 

VESSELS. 


Pericarditis. 

^Aneurysm   of   Thoracic 
Aorta. 


FIGURE  16. — POSSIBLE  AREAS  OF  PAIN  OR  TENDERNESS  IN  DISEASES  OF  THE  HEART 

AND  VESSELS. 


Atheroma  of  Aorta. 

Aneurysm  of  Aorta  or 
Coeliac  Axis. 

Valvular  Lesions  (espe- 
cially Aortic). 


FIGURE  17. — POSSIBLE  AREAS  OF  PAIN  OR  TENDERNESS  IN  DISEASES  OF  THE  HEART 

AND  VESSELS. 


Pericarditis. 


Descending  Aorta 


Abdominal  Aorta. 


Atheroma  of  Aorta. 

Aneurysm  of  Aorta. 

or  Innominate. 


Atheroma  of  Aorta. 

Aneurysm  of  Tho- 
racic or  Abdom- 
inal Aorta. 


FIGURE  13. — POSSIBLK  AREAS  OF  PAIN  on  TENDERNESS  IN  DISEASES  OF  THE  HEART  AND 

VESSELS. 


INDEX 


Abdomen,  56 

Abdominal  disorders,  29,  41, 59, 94 

Adhesions,  peritoneal,  244 

^Esophagus,  51 

Anaemia,  77 

Aneurysm  of  aorta,  303 

Angina  pectoris,  38 

Aorta,  49,  292 

Aortitis,  chronic,  308 

Apices,  pulmonary,  48 

Appendicitis,  220 

Appendix,  182 

Arm,  91 

Arthralgias,  103 

Biliary  congestion,  233 
Brain  tumor  and  hydrocephalus, 
71 

Calculi,  247,  263 
Cancer,  gastric,  164 
Carcinoma  of  colon,  221 

of  gall-ducts,  238 
Catarrhal  and  ulcerative  changes, 

272 

Circulatory  apparatus,  27,  50 
Cirrhosis  of  the  liver,  276 
Colic,  54 

and  thoracic  processes,  59 

doubtful  cases  of,  67 
Colicky  pains,  65 
Collapse,  54 

Congestion,  hsematogenous,  228 
Cysts,  241 

Defecation,  41 

Deglutition,  44 

Drugs  and  chemicals,  38,  280 


Embolism  of  the  renal  arteries,  250 
Epigastrium,  53,  54, 243 

midline  of,  211 
Epigastric  pain,  27 

Face,  88 

Food,  influence  of,  33,  54 

Gall-bladder,  211 

colic,  209 
Gall-stones,  63 
Gastralgias,  123 
Gastric  crises,  43 

disorders,  52 

pain,  40 

Hemorrhage,  247,  271 
Headache,  69 

and  constipation,  73 

caused  by  chemical  poisons, 
76 

of  reflex  nature,  78 
Hsemoglobinuria,  paroxysmal,  277 
Heart  or  epigastrium,  38 
Heart  disease,  277 
Hernias,  62 
Hysteria,  223 

Infectious  processes,  277 
Inflammations  of  aorta,  293 
Intercostal  spaces,  93 
Intestine,  malignant  new  growths 

of,  197 

Intestinal  stenoses,  62 
ulceration,  174 

Kidney,  222,  249,  258,  269 

Lead  colic,  192 

325 


326 


INDEX 


Lead  colic,  individual  symptoms 

and  analysis,  193 
Lesions,  abdominal,  42 
aortic,  296 
of  lungs,  291 
organic,  37 
Liver,  49,  51,  206 

capsule,  distention  of,  208 
inflammatory    processes, 

208,  228 

Lumbar  region,  57,  58,  212 
Lungs,  282 

Mediastinum,  50 
Menstruation,  45 
Motion,  organs  of,  26 
Myalgias  or  muscular  pains,  108, 

112,  113 
Myelogenous  leukaemia,  276 

Nephritis,  256 
Neuralgias,  61,  83,  97,  100 
New  growths,  cystic,  60 
Nocturnal  pains,  67 

Obstruction,  intestinal,  245 
Occipital  region,  90 
Osteomalacia,  119 
Ostalgias  or  bone  pains,  115, 122 

Pain,  sensation  of,  15-21 

of  colic,  65 
Pancreas,  240,  246 
Percussion,  31 
Peripheral  vessels,  314 
Perivesical  inflammations,  272 
Pleura,  284,  291 
Pleural  pain,  286 


Pneumonia,  292 
Position,  22,  55,  72 
Pressure,  29,  252 
Pyelitis,  268 
Pyloric  stenosis,  colic  of,  153 

Renal  infarct,  253,  256 
Respiration,  45 
Retrosternal  region,  50 

Scapula,  and  intrascapular  region, 

52 

Shoulder,  48 

Spasm  in  bile  passage  and   gall- 
bladder, 206 

of  the  urogenital  tract,  262 
Spleen,  276 

Stenotic  processes,  262 
Stomach,  51 

and  intestine,  79 
Suppurative  processes,  28 

True  kidney  pain,  249 
Tuberculosis  of  the  kidney,  259 

Ulcer,  duodenal,  220 

gastric,  133 

Ulceration,  gastric  and  duodenal, 
39 

intestinal,  174 

tuberculous  intestinal,  163 
Uremia,  76 
Urinary  bladder,  272 
Urination,  254 

Vagus,  97 
Valves,  aortic,  311 
Visceral  disease,  319-324 
Vomiting,  44 


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